This form should be filled out in the viewpoint of the minor client and preferably with their participation (as appropriate). The minor will be asked to co-sign upon completion of this form, although it's not required.
If yes, how many times per week? Excersise Per Week* and, how long? How Long*
If yes, how much per day? Packs/Day* and, how long have you been smoking? Years Smoking*
Parent/Guardian Acknowledgement: