| City, State | * |
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| How did you hear about us? | * |
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| Date | * |
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| Name | * |
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| Race/Ethnicity | * |
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| Year of Birth | * |
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| Smoker | * |
Yes
No
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| Have you smoked in the past | * |
Yes
No
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| If so, how long ago did you smoke and how long ago did you quit | * |
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| Ever been arrested | * |
Yes
No
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| If yes, explain | |
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| Were you convicted? | |
Yes
No
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| Height | * |
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| Weight | * |
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| Have you had a body piercing or tatoo within the past year? | * |
Yes
No
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| If yes, describe which one and give date of most recent | |
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| Are you drug and disease free? | * |
Yes
No
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| Have you experimented with drugs in the past | * |
Yes
No
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| If so, what, how many times, and how long since your last use | |
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| Marital Status | * |
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| Husband Supportive? | * |
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| How many children do you have? | * |
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| Ages | |
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| Occupation | * |
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| Employer | * |
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| Do you have insurance | * |
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| Provider | * |
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| Education | * |
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| Have you taken prescription medication in the past year? | * |
Yes
No
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| If so, what did you take, how long ago, and what were you being treated for? | |
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| What type of birth control do you use | * |
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| Have you ever taken antidepressants? | * |
Yes
No
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| If yes, when, what, and how long | |
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| Did you stop under a physicians care? | |
Yes
No
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| Date of last pap smear | * |
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| Date of last HIV test | * |
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| Home Phone | * |
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| Work Phone | * |
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| Cell Phone | * |
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| Address | * |
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| Email | * |
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