Alcohol Intake
Alcohol consumption
text
ALCOHOL CONVERTER 1 unit of alcohol in US = 1.5oz hard liquor, 1 beer, 4oz wine Round up/down to the nearest integer
integer
History of Tobacco Use
Nicotine oral regimen or topical application
text
DEFINITIONS • Never smoked Never smoked/used tobacco • Current smoker Currently smoking/using tobacco or has smoked/used tobacco within 6 months of screening visit • Former smoker Previously smoked/used tobacco and has not smoked/used tobacco for at least 6 months prior to screening visit
integer
Last smoke
date
CONVERTER FOR TOBACCO PRODUCTS 1 cigar = 7 cigarettes 1 gram (or 0.03 oz.) of tobacco = 1 cigarette
integer
Number of years smoking
integer
CALCULATION FOR NUMBER OF PACK YEARS Average number of cigarettes smoked per day x number of years smoked 20 Round up/down to the nearest integer
integer
Drug and Alcohol Screen
Date sample taken
date
Time sample taken
time
If positive, exclude subject from the study.
integer
If positive, exclude subject from the study.
integer
If positive, exclude subject from the study.
integer
If positive, exclude subject from the study.
integer
If positive, exclude subject from the study.
integer
If positive, exclude subject from the study.
integer
If any of the above are positive, exclude subject from the study.
integer
Laboratory Tests - Urine Cotinine