How intense is your typical exercise? (Check one)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
0= Not at all | 1= Several Days | 2= More than half the days | 3= Nearly everyday
If yes, please answer the following questions below. Thank you!
Tobacco (Chew, Cigar, Pipe, Cigarette)
In the past 2 years….
** TB test is needed if the answer is YES to any of the above questions. Proceed with office
protocol at that point. If the answer is NO then no further action is required. **
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1377 S. Grand Ave Glendora, CA 91740 Phone 626-483-3348 Fax 626-623-7258
Sept 2019 VERSION 2.0
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