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Medicare Annual Wellness Visit Health Risk Assessment NAME: DOB: A. Social History Do you smoke?.................. No CESIF Yes, packs/day? Do you drink alcohol?........ No CESIF Yes, drinks/week?
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Anyone who is required to provide information about their packs per day may need to fill out the packsday form. This could include individuals being surveyed for research purposes, patients in a medical study, or individuals seeking assistance or support for tobacco addiction.
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