PREPARED FOR THE STAFF NURSES OF THE

5. Are you taking any prescribed medication on a regular basis for a physical problem? Yes No. If yes please list: 6. How many days in the last 30 have you experienced medical problems? _____ (If answer is greater than 0 proceed to #7. If not proceed to #8) 7. How troubled have you been in the last 30 days by these medical problems? ................
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