NEW PATIENT QUESTIONNAIRE - Christiana Spine
dye/contrast allergy. iodine allergy. Tobacco/ Nicotine. History: never current former (quit date: ) cigarettes . pack(s) per day . year(s) smoked . other (please list) year(s) used . History of: Substance abuse. Alcohol abuse (Please use your pen to mark painful areas) Front. Back. Currently working? ................
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