Informed Consent - Only Minimal Risk Template (ADA ...

List any allergies that you have _____ _____ Have you ever been diagnosed with Depression? Yes No. Over the past two weeks, how often have you been bothered by any of the following problems? ... Do you have any other medical conditions? (please specify): _____ _____ Do you use tobacco? Yes No Quit (If No, go to question 37) What type of tobacco ... ................
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