ChristianaCare

Christiana Care Neurology SpecialistsPatient’s Name & DOB____________________________________Date_____________________Tobacco useCaffeine UseAlcohol Use Street Drugs____never smoked____ none____ Never ____ no use____current smoker ____ packs per day____ 1-3 cups per day____ Minimal ____ Other_____________previous smoker ____ packs per day____ 4-6 cups per day____ Moderate _______________________chews tobacco____ 6 + cups per day____ Heavy ................
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