• Primary, Spouse or Child?NameGender (M/F)Date of Birth (MM/DD/YY)Tobacco Use (Y/N) 
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  • Never
    (0 times)
    Rarely
    (1-3 times)
    Sometimes
    (4-6 times)
    Often
    (7 or more)
    Preventive visits to your primary care doctor
    Sick visits to your primary care doctor
    See a specialist for ongoing health issue
    Stay overnight in the hospital
    Fill prescription medications
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