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| The questions asked to the patient in this questionnaire submission. |
| May contain organization-specific values: No |
| Category Entries: |
| History Comment |
| History Date |
| Smoking Status |
| Smoking Type |
| Smoking Average Packs Per Day |
| Smoking Total Years |
| Smoking Start Date |
| Smoking Quit Date |
| Smokeless Status |
| Smokeless Type |
| Smokeless Quit Date |
| Tobacco Ready to Quit |
| History Use Status |
| History Use Per Week |
| History Types |
| Sexually Active |
| Sex Partners |
| Sex Birth Control / Protection |
| Smoking Current Packs Per Day |
| Smoking Current Years |
| Smoking Current Cigarettes Per Day |
| Smoking Average Cigarettes Per Day |
| Mammography Baseline Exam |
| Mammography Last Exam Performed at External Facility |
| Mammography Last Exam Facility Name |
| Mammography Last Exam Facility Comment |
| Mammography Last Exam Procedure |
| Mammography Last Exam Procedure Comment |
| Mammography Last Exam Date |
| Mammography Breast Self-Exams |