yesno

    yesno


    goodokunsatisfactorypoor


    very goodgoodokunsatisfactorypoor


    yesno If so, for how long?

    yesno If so, please specify and tell me when this began.

    yesno




    dailyweeklymonthlyinfrequentlynever

    yesnoIf so, for how long?:

    In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, aunt etc)

    yesno

    yesno

    yesno

    yesno

    yesno

    yesno

    yesno

    yesno

    yesno


    yesno

    yesno

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