Quick Primary Care

8550 SW State Road 200
Ocala, FL 34481

Phone: 352-854-9110

Fax: 352-854-9119

QPC New Patient - Page 5

Page 5 of 9 — complete the fields below and submit.

Quick Primary Care

Personal Information - Page 5 of 9

New Patient Date

Currently Smoking?

Do you smoke? *

Previous Smoker?

Have you ever smoked before? *

Any Alcohol?

Do you drink alcohol? *

Coffee/Caffeine?

Do you drink coffee? *

Exercise?

Do you exercise? *

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