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Ease Arthritis Asthma Cancer Patient Name: Diabetes DOB: Hypertension Other: SOCIAL HISTORY: Single Married Partnered Separated Divorced Widowed Tobacco Use: (please choose one) Never Former (Quit date) Current (How many years?) Packs/day: Occasional Moderate Drinks/week: Drugs used: Alcohol Use: (please choose one) Never Rare Illicit Drug Use: Yes No Prescription Drug Abuse: Yes No Daily Drugs used: Occupation: Employer: Time on yo.

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