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Demographic Information
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Race / Ethnicity
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Patient Gender
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Gender Expression
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I chose to idenify as
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Sexual Orientation
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I chose to idenify as (Preferred pronoun)
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Living Arrangements
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Patient Living Arrangements
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Household Members
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Patient's Children (sex & age)
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Educational History
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Highest Level of Education Completed
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Current Educational Setting
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Special Education
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History of Learning Problems
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Other Education Related Concerns:
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Vocational History
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History of Steady Employment:
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Current Employment Status
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Other:
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Military History
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Have you served in the military?
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If yes, What branch?
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Are you active duty?
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If no, Type of discharge
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Legal History
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Past or Current Legal Problems
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Court Ordered Treatment:
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If yes, please explain:
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Medical History
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Current or past medical conditions (check all that apply)
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Other, Please describe
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If sexually active, are you using birth control?
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Have you had surgery or have you been hospitalized?
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If yes, Please describe
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Do you have a primary care doctor?
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Primary Care Doctor
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Are you currently taking any prescribed medication?
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List all current (Medications, doses, frequencies), (M,D,F), (M,D,F) . . .
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Please list any allergies
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Substance Use History
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Do you currently use or have you used tobacco?
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Tobacco - type & frequency
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Do you currently use or have you used alcohol?
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Alcohol - Amount/How often
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Do you currently use or have you used Marijuana?
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Marijuana - How often
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Do you currently use or have you used any other substances?
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Any other substances - How often
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