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Personal Information - Page 5 of 9
New Patient Info (Continued...)
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Currently Smoking ?
Do you smoke ?
Yes
No
If yes, How many packs per day ?
For how many years ?
Previous Smoker?
If no, were you previous smoker ?
Yes
No
When did you quit ?
How long did you smoke ?
Any Alcohol ?
Do you drink alcohol ?
Yes
No
If yes, How much per day ?
Coffee Drinker ?
Do you drink coffee ?
Yes
No
If yes, How much per Day ?
Exercise ?
Do you exercise ?
Yes
No
How frequently ?
If yes, what type ?
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