Microsoft Word - Keays Medical Group
56 Are there times when you drink very heavily for one or more days in a row?Y N. If "yes" how often? Do you use drugs or medication that affect your mood or help you to relax? Y N. If "yes" how often? Occupational History. Please provide a list of your all jobs performed in the last five years: DatesEmployerPositionHazardous Exposure? 1. 2. 3 ... ................
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