Medication, Immunizations, Alcohol, & Cigarette Use

1.    Have you ever had a bad reaction to medication (circle one)?        Yes     No

      If yes, list which ones and how they affected you (e.g. rash, trouble breathing, confusion, etc).


2.    Do you get a flu shot every year (circle one)?    Yes     No

3.    Have you ever had the pneumonia vaccine (circle one)?    Yes     No

4.    How much alcohol do you drink?  Has drinking ever affected your family or work?  Has anyone suggested you cut down?


5.    How much do you smoke?  Did you smoke in the past?  How many years and how much?
 

List all PRESCRIPTION and OVER-THE-COUNTER MEDICATIONS you have taken in the past month.
(include vitamins, natural remedies, etc)