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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

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



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    July 18, 2018

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