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ARDIAC VASCULAR SKIN EARS HEAD/EYES GENERAL MEDICAL HISTORY Periodic Other Current Smoker # cigarettes/day Former Smoker # cigarettes/day Never Smoked What is your average alcohol consumption (#drinks/week)? If you drink, what is your usual pattern of drinking? Do you use recreational drugs? Type of exercise or activity you do Intensity? Low (walking) Duration of exercise in minutes/session List all current medications No Yes total yrs. smoked total yrs. smoked drinks Weekends Weekda.

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