PRIORITY PRIVATE CARE
SOCIAL HISTORY
Tobacco Use (cigarettes)
Other Tobacco Used
❑ Pipe ❑ Cigar ❑ Snuff ❑ Chew
Do you drink alcohol?
Number of drinks per week:
Is your alcohol use a concern for you or others?
❑ Yes ❑ No
Caffeine intake (cup ner day incliidinn raft'," tea and soda
(please state if none)
170 East 77th Street, New York, NY 1007
EFTA00314176
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