What is your current cigarette smoking status?
At what age did you begin smoking?
How many cigarettes do you currently smoke or did you previously smoker per day?
If you quit smoking, at what age did you quit?
How many cigars or pipes do you smoke per week?
How many cans of smokeless / chewing tobacco do you use per week?
How often do you use alcohol?
HIV High Risk Behavior
(HIV Risk Factors: IV drug use, More than one sexual partner, Sex with a prostitute, Unprotected sexual contact, Contact with contaminated injection equipment.)
YOUR Medical History
Please indicate if YOU have a history of the following:
Please indicate if YOUR FAMILY has a history of the following: (ONLY include parents, grandparetns, siblings, and children)