Dr. Gerald B Harris, II

First and Last Name * Date of Birth * Age * Today's Date * Have you had any of the following problems: * Do you have any of the following problems: * Relation to You and Type: Have you ever used tobacco? *

Only answer these 4 questions if you selected yes to the previous question.

How may packs a day? Number of years smoked Year you quit When are you planning to quit? Do you drink alcohol? *

Only answer the next 4 questions if you selected yes to the previous question regarding alcohol.

Have you ever felt you should cut down on your drinking? Have people ever annoyed you by nagging you about your drinking? Have you ever felt guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? Anyone in the family have history of prostate or intestine cancer? Anyone in the family with a history of heart pain or heart attacks before the age of 55?