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
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? ___________
Have you ever used recreational drugs? □ No □ Yes
If yes, which ones? __________________________________
Quit which ones? □ All _______________________________
Any used currently? _________________________________
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
Military Service? □ No □ Yes
Exposure to toxic chemicals at work?
Exposure to toxic chemicals doing hobbies?
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
Do you have little interest or pleasure in doing things?□ No
ease continue to next column on right
oes your home have a working
Do you have guns
in your home?
If yes, are they locked
up & ammo
Have you or any family
members ever been
hurt, insulted, threatened or screamed at?
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