On average, how many pipefuls of tobacco do you smoke each day?
On average, how many other tobacco products do you smoke each day? (excluding manufactured cigarettes, hand-rolled cigarettes, pipefuls of tobacco)
Have you ever consumed a drink that contains alcohol (such as beer, wine, etc.)?
How many standard drinks of any alcoholic beverage did you have on Monday?
How many standard drinks of any alcoholic beverage did you have on Tuesday?
How many standard drinks of any alcoholic beverage did you have on Wednesday?
How many standard drinks of any alcoholic beverage did you have on Thursday?
How many standard drinks of any alcoholic beverage did you have on Friday?
How many standard drinks of any alcoholic beverage did you have on Saturday?
How many standard drinks of any alcoholic beverage did you have on Sunday?
How many servings of fruit do you eat on a typical day?
Over the last 5 years, was there ever a time you stayed overnight in a hospital or other type of long term care facility for your own health care?
Over the last 5 years, was there ever a time that one of your children aged 12 years or less stayed overnight in a hospital (for his/her own health care)?
What is the sex of the child?
What is the date of birth of the child?
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