PRIORITY PRIVATE CARE SOCIAL HISTORY Tobacco Use (cigarettes) Other Tobacco Used ❑ Pipe ❑ Cigar Do you drink alcohol? ❑ Snuff ❑ Chew Number of drinks per week: Is your alcohol use a concern for you or others? ❑ Yes ❑ No Caffeine intake (cup ner day incliidinn raft'," tea and soda (please state if none) 170 East 77th Street, New York, NY 1007 EFTA00314176