Your Psychiatric History:
MEDICAL HISTORY: (Please be truthful 100% - Put checkmarks in the table): Condition Yes. Check No. Check Comments –treated in hospital, which drug/meds used etc Diabetes High Blood Pressure Thyroid Problems Weight Loss (Anorexia) Weight Gain (Obesity) Cancer Asthma Seizures Head Injury Pain Sex Problems Bladder Problems Surgeries ................
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