HISTORY OF TOBACCO USE
If current smoker, Exclude subject from study. DEFINITIONS: Never smoked: Never smoked Current smoker: Currently smoking or has smoked within 6 months of screening visit Former smoker: Previously smoked and has not smoked for at least 6 months prior to screening visit
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SEROLOGY - HIV SCREEN
day month year
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Tick appropriate box(es)
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If any screen are positive, exclude subject from the study.
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