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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

    YesNoX

    YesNoX

    YesNoX

    YesNoX

    YesNoX

    YesNoX

    YesNoX

    YesNoX

    YesNoX

    YesNoX

    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

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