NAME:
Yes
No
Do you smoke?
AGE:
Any major health issues (i.e. cancer, heart attack,
stroke, etc)?
Yes
No
Diabetes
COPD
None
Any diabetes or COPD?
SPOUSE:
Yes
No
Do you smoke?
AGE:
Any major health issues (i.e. cancer, heart attack,
stroke, etc)?
Yes
No
Diabetes
COPD
None
Any diabetes or COPD?
Address:
Phone:
Email: