__
______________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________
HEALTH ISSUES:
Toba
cco Use:
Smoke or smoked cigarettes/ pipe/ cigars (circle)?
□ Never □ Yes
Exposure to second hand smoke? □ No □ Yes
(If never used any tobacco can skip to Alcohol Use section below)
Current smoker: Packs/day: _________ # of years: _________
Former smoker: Quit date: __________
Approximately how many packs/day did you smoke? _______
How many years did you smoke? ________
Other tobacco? (circle) Snuff or Chew
Quit date ________ Currently use? □ Yes
Are you ready to quit? □ No □ Yes
Alcohol Use:
Do you drink alcohol? □ No □ Yes
# of drinks/week: ___________ □ Beer □ Wine □ Liquor
How many times in a year have you had >3 drinks (for women)
>4 drinks (for men) in a day? ___________
Drug Use:
Have you ever used recreational drugs? □ No □ Yes
If yes, which ones? __________________________________
Quit which ones? □ All _______________________________
Any used currently? _________________________________
Sexual Activity:
Are you sexually involved: □ Not currently □ Never □ Yes
Sexual partner(s) is/are/have been/may be in future:
□ male □ female
Birth control method or STD prevention (check all that apply):
□ None needed □ Condom □ Pill □ IUD □ Patch □ Ring
□ Diaphragm □ Vasectomy □ Tubal ligation
□ Other method
(specify):____________________________________________
Other (ADL):
Military Service? □ No □ Yes
B
lood Transfusion?
Exposure to toxic chemicals at work?
Exposure to toxic chemicals doing hobbies?
Diet:
D
o you follow a special diet?
vegetarian, vegan, gluten free, other
Exercise: Do you exercise regularly?
If yes, what kind of exercise?
□ No □ Yes
□ No □ Yes
□
No □ Yes
□ No □ Yes
________________
□ Yes □ No
______________________________
How long (minutes)? _____________ How often? ______________
Do you use a helmet for recreational activities?
(e.g. bike, skateboard, ski) □ Not applicable □ Yes □ No
Do you use seatbelts consistently? □ Yes □ No
In the past 2 weeks: Have you been feeling down, depressed or
hopeless? □ No
Yes
Do you have little interest or pleasure in doing things?□ No
□
□ Yes
Pl
ease continue to next column on right
SAFETY:
D
oes your home have a working
smoke detector?
□ Y
es □
No
Do you have guns
in your home?
□ No
□
Yes
If yes, are they locked
up & ammo
stored
separately?
□ Yes
□
No
Have you or any family
members ever been
hurt, insulted, threatened or screamed at?
□ No
□
Yes
S
OCIAL DOCUMENTATION:
Name you prefer we use when contacting you (nickname, first, or last with Mr, Mrs, Ms, etc): ________________________________
Country of birth: ____________________________________________
Who lives at home with you: □ No one □ Spouse/partner □ Children _________________________________________________
□ Pets (what type) ____________________ □ Other (roommates, extended family, etc) ________________________
Please list your interests, hobbies, group involvement, volunteer work, and/or travel outside of country in the past 6 months:
Revised 7/10/2015 please go to next page Page 5 of 6
