Adult Medical History Form - Company Name

How many? _____ 5 oz. glasses of wine _____ 12 oz. cans of beer _____ shots of liquor ☐Daily ☐Weekly ☐Monthly . Do you drink more when you smoke? ☐Yes ☐No . Do you smoke more when you drink? ☐Yes ☐No. Drug Use: ☐Yes ☐No. Family History. Please check any of the following that your family members have had. Check any that apply and specify who has had that disease. Disease. Who ... ................
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