History Sheet

Name:______________________________        Date:__________________

Address:____________________________________________________

Phone Number:_________________ Male/Female (circle one) Pregnant____

Medications currently being taken:________________________________________________

Number of years smoked/chewed:_________________

Number of packs/cans per day:______________ Cigars per day:_____________

Pipe loads per day:__________        Date of Birth:____________________

Pre-existing medical conditions: Check only if present

Shortness of breath __ Dizziness__ Coughing__

High Blood Pressure__ Diabetes__ Cancer__

Lung Disease__ Digestive Problems__ Heartburn__

Tuberculosis__ Bowel disease__ Alcohol abuse__

Allergies:______________________ Weight:__________

back to Smoking Cessation

Blood Pressure: _____/_____ Pulse:_____ Respiration:_____

Accepted___ Rejected___

Comments:___________________________________________________________________

Two Week Call Back Date:_________

Response:__________________________________________________________________________________________________________________