Medical Assessment

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Medical and Psychiatric History

Please select either "Yes " or "No" or "X" for "Don't know". Answer all questions.


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Medical and Psychiatric History

Please select either "Yes " or "No" or "X" for "Don't know". Answer all questions.


YesNoX

YesNoX

YesNoX

YesNoX

YesNoX

Please provide the name, age and address of the adult who has agreed to supervise your medication, should you be issued with a prescription.



YesNoX

July 18, 2018

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