3. Personal Habits
Tobacco Use
Cigarettes: Never Quit-Date______ Current Smoker-Packs per day___ # of years___
Other tobacco: Pipe
Cigar
Snuff
Chew
Are you interested in quitting?
Yes
No
Alcohol Use
Do you drink alcohol?
No
Yes, average # of drinks per week_____
If no, have you in the past?
Yes
No
Drug Use
Do you use any recreational drugs, such as marijuana, cocaine, stimulants, narcotics, diet pills?
Yes
No
Have you ever used needles?
Yes
No.
Sexuality
Are you sexually active?
Yes
No
Not currently
If sexually active, do you practice safe sex? Yes
No
Birth control method________________
Have you ever had any sexually transmitted diseases (STD's)? Yes
No
If yes, please include___________________________________________________________
Exercise
Do you exercise regularly?
Yes
No
If yes, what type of exercises?____________________________________________________
Emotions
In the past year, have you had 2 weeks or more during which you felt sad, blue, or depressed;
or when you lost interest or pleasure in things that you usually enjoyed?
Yes
No
4. Medications
Please list all your current medications, including medications/supplements not needing a prescription:
Medication
Dose and Directions
___________________________________ ______________________________________________
___________________________________ ______________________________________________
___________________________________ ______________________________________________
___________________________________ ______________________________________________
___________________________________ ______________________________________________
___________________________________ ______________________________________________
___________________________________ ______________________________________________
5. Allergies
Please list any allergies or reactions to medications:
Medication
Reaction or Side Effect
___________________________________ ______________________________________________
___________________________________ ______________________________________________
___________________________________ ______________________________________________
___________________________________ ______________________________________________