The following form must be completed prior to your visit. 
Have you or anyone in your houshold had any of the following signs or symptoms in the last 14 days? 
Please check either No or Yes for the following questions. If answering Yes, please give further details in the space provided. 
Do you suffer from, or have you ever had any of the following conditions? 
Number per day on average
Rolling tobacco
Chewing tobacco
Nasal snuff
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