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Ase Cancer Gastrointestinal Problems ( ( ( ( ) ) ) ) ( ( ( ( ) ) ) ) ( ( ( ( ) ) ) ) ( ( ( ( ) ) ) ) Anemia Bleeding Disorder Diabetes ( ) ( ) ( ) ( ) ( ) ( ) SOCIAL HISTORY: Do you drink alcohol? Do you smoke? Cultural / language barriers? Advanced directives? Physician s signature: ( ) ( ) ( ) occasional ( pack-less/day ) 1/day ( ) ( ) 2-3/day 1pack/day ( ) 4+/day ( ) 1+pack/day Date / / RANDI J. KATZ, D.O. RAGHU K. KUNAMNENI, M.D. KENNETH D. NAHUM, D.O.,.

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