Adult Health Assessment Form - Pennsylvania
SUBST ANCE & SE XUALI TY
Tobacco Use
I have NEVER smoked
I smoked in the past but I have QUIT
I am exposed to PASSIVE smoke
YES I currently smoke
How much did or do you smoke ? Packs/Day
How long had or have you smoked ? Years
When did you most recently quit ? Date Quit
What kind of tobacco do you use ? Cigarettes
Pipe
Cigar
Snuff
Comment_______________________________________ Chew
Alcohol Use I don't consume alcohol
I consume alcohol on occasion
How many drinks containing 0.5 oz of
alcohol do you consume per week ? Can(s) of beer
Glass(es) of wine
Comment_______________________________________ Shot(s) of liquor
Drug Use
I don't use drugs
I use drugs on occasion
Please indicate your frequency of
use per weeks for each substance:
IV
Cocaine
Marijuana
Comment_______________________________________ Other
Sexual Activity I am not currently sexually active
I have never been sexually active
I am sexually active at present
I partner with Male
Female
I use the Birth control/Protection Condom
Pill
Diaphragm
IUD
Surgical
Spermicide
Implant
Rhythm
Injection
Sponge
Inserts
Comment_______________________________________ Abstinence
Name
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