Detailed Adult History Form Page 4
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6I have never smoked ________
I quit smoking ________ years ago
I presently smoke
YES
NO
I am exposed to second hand smoke
YES
NO
If yes, from:
Spouse
Work Environment
Home
Daily
Weekly
OCC
Rarely
Social
Do you use any of the following?
Cigarettes
YES
NO
Packs per day _______
How many years? _____
Pipe
YES
NO
Hours per day _______
How many years? _____
Cigars
YES
NO
Number per day ____
How many years? _____
Chewing Tobacco
YES
NO
How many years? _____
Snuff
YES
NO
How many years? _____
Have you tried to quit smoking?
YES
NO
If yes, when?
What type of “help” did you seek? _______________________________________________
Do you use any of the caffeine products listed below?
COFFEE
YES
NO
Number of cups per day __________
TEA
YES
NO
Number of cups per day __________
POP
YES
NO
Number of cups per day __________
Section 8: Family Medical History
What is the medical history of your family members (Mother, Father, Brother, Sister,
Grandparent)?
Anemia
YES
NO
Lung Disease
YES
NO
Blood Clots
YES
NO
Mental Health Issues
YES
NO
Cancer (Type _____________)
YES
NO
Sickle Cell
YES
NO
Diabetes
YES
NO
Stroke
YES
NO
High B/P
YES
NO
Thyroid Problems
YES
NO
Heart Problems
YES
NO
Tuberculosis
YES
NO
OTHER: __________________________________________________________________
*A8490125
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