{\rtf1\adeflang1025\ansi\ansicpg1252\uc1\adeff0\deff0\stshfdbch31505\stshfloch31506\stshfhich31506\stshfbi0\deflang2057\deflangfe2057\themelang2057\themelangfe0\themelangcs0{\fonttbl{\f0\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f1\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604020202020204}Arial;}
{\f2\fbidi \fmodern\fcharset0\fprq1{\*\panose 02070309020205020404}Courier New;}{\f3\fbidi \froman\fcharset2\fprq2{\*\panose 05050102010706020507}Symbol;}{\f10\fbidi \fnil\fcharset2\fprq2{\*\panose 05000000000000000000}Wingdings;}
{\f34\fbidi \froman\fcharset0\fprq2{\*\panose 02040503050406030204}Cambria Math;}{\f37\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}{\f38\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604030504040204}Tahoma;}
{\f39\fbidi \fnil\fcharset0\fprq2{\*\panose 02000600000000000000}Segoe Print;}{\flomajor\f31500\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fdbmajor\f31501\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fhimajor\f31502\fbidi \froman\fcharset0\fprq2{\*\panose 02040503050406030204}Cambria;}
{\fbimajor\f31503\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\flominor\f31504\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fdbminor\f31505\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fhiminor\f31506\fbidi \fswiss\fcharset0\fprq2{\*\panose 020f0502020204030204}Calibri;}
{\fbiminor\f31507\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f40\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\f41\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\f43\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\f44\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\f45\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\f46\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\f47\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\f48\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\f50\fbidi \fswiss\fcharset238\fprq2 Arial CE;}{\f51\fbidi \fswiss\fcharset204\fprq2 Arial Cyr;}
{\f53\fbidi \fswiss\fcharset161\fprq2 Arial Greek;}{\f54\fbidi \fswiss\fcharset162\fprq2 Arial Tur;}{\f55\fbidi \fswiss\fcharset177\fprq2 Arial (Hebrew);}{\f56\fbidi \fswiss\fcharset178\fprq2 Arial (Arabic);}
{\f57\fbidi \fswiss\fcharset186\fprq2 Arial Baltic;}{\f58\fbidi \fswiss\fcharset163\fprq2 Arial (Vietnamese);}{\f60\fbidi \fmodern\fcharset238\fprq1 Courier New CE;}{\f61\fbidi \fmodern\fcharset204\fprq1 Courier New Cyr;}
{\f63\fbidi \fmodern\fcharset161\fprq1 Courier New Greek;}{\f64\fbidi \fmodern\fcharset162\fprq1 Courier New Tur;}{\f65\fbidi \fmodern\fcharset177\fprq1 Courier New (Hebrew);}{\f66\fbidi \fmodern\fcharset178\fprq1 Courier New (Arabic);}
{\f67\fbidi \fmodern\fcharset186\fprq1 Courier New Baltic;}{\f68\fbidi \fmodern\fcharset163\fprq1 Courier New (Vietnamese);}{\f380\fbidi \froman\fcharset238\fprq2 Cambria Math CE;}{\f381\fbidi \froman\fcharset204\fprq2 Cambria Math Cyr;}
{\f383\fbidi \froman\fcharset161\fprq2 Cambria Math Greek;}{\f384\fbidi \froman\fcharset162\fprq2 Cambria Math Tur;}{\f387\fbidi \froman\fcharset186\fprq2 Cambria Math Baltic;}{\f388\fbidi \froman\fcharset163\fprq2 Cambria Math (Vietnamese);}
{\f410\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\f411\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}{\f413\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\f414\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}
{\f417\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}{\f418\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\f420\fbidi \fswiss\fcharset238\fprq2 Tahoma CE;}{\f421\fbidi \fswiss\fcharset204\fprq2 Tahoma Cyr;}
{\f423\fbidi \fswiss\fcharset161\fprq2 Tahoma Greek;}{\f424\fbidi \fswiss\fcharset162\fprq2 Tahoma Tur;}{\f425\fbidi \fswiss\fcharset177\fprq2 Tahoma (Hebrew);}{\f426\fbidi \fswiss\fcharset178\fprq2 Tahoma (Arabic);}
{\f427\fbidi \fswiss\fcharset186\fprq2 Tahoma Baltic;}{\f428\fbidi \fswiss\fcharset163\fprq2 Tahoma (Vietnamese);}{\f429\fbidi \fswiss\fcharset222\fprq2 Tahoma (Thai);}{\f430\fbidi \fnil\fcharset238\fprq2 Segoe Print CE;}
{\f431\fbidi \fnil\fcharset204\fprq2 Segoe Print Cyr;}{\f433\fbidi \fnil\fcharset161\fprq2 Segoe Print Greek;}{\f434\fbidi \fnil\fcharset162\fprq2 Segoe Print Tur;}{\f437\fbidi \fnil\fcharset186\fprq2 Segoe Print Baltic;}
{\flomajor\f31508\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\flomajor\f31509\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\flomajor\f31511\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\flomajor\f31512\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flomajor\f31513\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flomajor\f31514\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\flomajor\f31515\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flomajor\f31516\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbmajor\f31518\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\fdbmajor\f31519\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbmajor\f31521\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbmajor\f31522\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\fdbmajor\f31523\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbmajor\f31524\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbmajor\f31525\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fdbmajor\f31526\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhimajor\f31528\fbidi \froman\fcharset238\fprq2 Cambria CE;}{\fhimajor\f31529\fbidi \froman\fcharset204\fprq2 Cambria Cyr;}
{\fhimajor\f31531\fbidi \froman\fcharset161\fprq2 Cambria Greek;}{\fhimajor\f31532\fbidi \froman\fcharset162\fprq2 Cambria Tur;}{\fhimajor\f31535\fbidi \froman\fcharset186\fprq2 Cambria Baltic;}
{\fhimajor\f31536\fbidi \froman\fcharset163\fprq2 Cambria (Vietnamese);}{\fbimajor\f31538\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbimajor\f31539\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\flominor\f31548\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\flominor\f31549\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\flominor\f31551\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\fdbminor\f31559\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbminor\f31561\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbminor\f31562\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}
{\fhiminor\f31571\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\fhiminor\f31572\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}
{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\fbiminor\f31578\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbiminor\f31579\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fbiminor\f31581\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbiminor\f31585\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbiminor\f31586\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}
{\colortbl;\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255;\red0\green255\blue0;\red255\green0\blue255;\red255\green0\blue0;\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue128;\red0\green128\blue128;\red0\green128\blue0;
\red128\green0\blue128;\red128\green0\blue0;\red128\green128\blue0;\red128\green128\blue128;\red192\green192\blue192;\caccentfive\ctint51\cshade255\red218\green238\blue243;\red0\green32\blue96;\caccentsix\ctint102\cshade255\red251\green212\blue180;
\caccentsix\ctint51\cshade255\red253\green233\blue217;\caccenttwo\ctint51\cshade255\red242\green219\blue219;\red255\green255\blue204;\red255\green255\blue255;}{\*\defchp \fs22\loch\af31506\hich\af31506\dbch\af31505 }{\*\defpap
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 }\noqfpromote {\stylesheet{\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\fs24\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 \snext0 \sqformat \spriority0 \styrsid3829546 Normal;}{
\s1\ql \li0\ri0\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs32\alang1025 \ltrch\fcs0
\b\fs32\lang2057\langfe2057\kerning32\loch\f31502\hich\af31502\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext0 \slink15 \sqformat \spriority9 \styrsid3829546 heading 1;}{
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\b\i\fs28\lang2057\langfe2057\loch\f31502\hich\af31502\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext0 \slink16 \sunhideused \sqformat \spriority9 \styrsid3829546 heading 2;}{
\s3\ql \li0\ri0\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs26\alang1025 \ltrch\fcs0
\b\fs26\lang2057\langfe2057\loch\f31502\hich\af31502\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext0 \slink17 \sunhideused \sqformat \spriority9 \styrsid3829546 heading 3;}{
\s4\ql \li0\ri0\sb240\sa60\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel3\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0
\b\fs28\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext0 \slink18 \sunhideused \sqformat \spriority9 \styrsid3829546 heading 4;}{
\s5\ql \li0\ri0\sb240\sa60\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel4\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\ai\af0\afs26\alang1025 \ltrch\fcs0
\b\i\fs26\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext0 \slink19 \ssemihidden \sunhideused \sqformat \spriority9 \styrsid3829546 heading 5;}{
\s6\ql \li0\ri0\sb240\sa60\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel5\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs22\alang1025 \ltrch\fcs0
\b\fs22\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext0 \slink20 \ssemihidden \sunhideused \sqformat \spriority9 \styrsid3829546 heading 6;}{
\s7\ql \li0\ri0\sb240\sa60\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel6\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057
\sbasedon0 \snext0 \slink21 \ssemihidden \sunhideused \sqformat \spriority9 \styrsid3829546 heading 7;}{\s8\ql \li0\ri0\sb240\sa60\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel7\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ai\af0\afs24\alang1025
\ltrch\fcs0 \i\fs24\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext0 \slink22 \ssemihidden \sunhideused \sqformat \spriority9 \styrsid3829546 heading 8;}{
\s9\ql \li0\ri0\sb240\sa60\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel8\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang2057\langfe2057\loch\f31502\hich\af31502\dbch\af31505\cgrid\langnp2057\langfenp2057
\sbasedon0 \snext0 \slink23 \ssemihidden \sunhideused \sqformat \spriority9 \styrsid3829546 heading 9;}{\*\cs10 \additive \ssemihidden \sunhideused \spriority1 \styrsid3829546 Default Paragraph Font;}{\*
\ts11\tsrowd\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3\tsvertalt\tsbrdrt\tsbrdrl\tsbrdrb\tsbrdrr\tsbrdrdgl\tsbrdrdgr\tsbrdrh\tsbrdrv
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \fs22\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057
\snext11 \ssemihidden \sunhideused Normal Table;}{\*\cs15 \additive \rtlch\fcs1 \ab\af0\afs32 \ltrch\fcs0 \b\f31502\fs32\kerning32 \sbasedon10 \slink1 \slocked \spriority9 \styrsid3829546 Heading 1 Char;}{\*\cs16 \additive \rtlch\fcs1 \ab\ai\af0\afs28
\ltrch\fcs0 \b\i\f31502\fs28 \sbasedon10 \slink2 \slocked \spriority9 \styrsid3829546 Heading 2 Char;}{\*\cs17 \additive \rtlch\fcs1 \ab\af0\afs26 \ltrch\fcs0 \b\f31502\fs26 \sbasedon10 \slink3 \slocked \spriority9 \styrsid3829546 Heading 3 Char;}{\*
\cs18 \additive \rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 \b\fs28 \sbasedon10 \slink4 \slocked \spriority9 \styrsid3829546 Heading 4 Char;}{\*\cs19 \additive \rtlch\fcs1 \ab\ai\af0\afs26 \ltrch\fcs0 \b\i\fs26
\sbasedon10 \slink5 \slocked \ssemihidden \spriority9 \styrsid3829546 Heading 5 Char;}{\*\cs20 \additive \rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b \sbasedon10 \slink6 \slocked \ssemihidden \spriority9 \styrsid3829546 Heading 6 Char;}{\*\cs21 \additive
\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24 \sbasedon10 \slink7 \slocked \ssemihidden \spriority9 \styrsid3829546 Heading 7 Char;}{\*\cs22 \additive \rtlch\fcs1 \ai\af0\afs24 \ltrch\fcs0 \i\fs24
\sbasedon10 \slink8 \slocked \ssemihidden \spriority9 \styrsid3829546 Heading 8 Char;}{\*\cs23 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \f31502 \sbasedon10 \slink9 \slocked \ssemihidden \spriority9 \styrsid3829546 Heading 9 Char;}{\s24\ql \li0\ri0\widctlpar
\tqc\tx4153\tqr\tx8306\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057
\sbasedon0 \snext24 \slink25 \styrsid1205517 header;}{\*\cs25 \additive \rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f1\fs24\lang0\langfe1033\langnp0\langfenp1033 \sbasedon10 \slink24 \slocked \ssemihidden Header Char;}{\s26\ql \li0\ri0\widctlpar
\tqc\tx4153\tqr\tx8306\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057
\sbasedon0 \snext26 \slink27 \styrsid3307999 footer;}{\*\cs27 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \fs24\lang0\langfe1033\langnp0\langfenp1033 \sbasedon10 \slink26 \slocked Footer Char;}{\*\cs28 \additive \b\f1\fs20\cf1 \spriority0 \styrsid3285040
Headers or Fields;}{\*\cs29 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \ul\cf2 \sbasedon10 \styrsid12201408 Hyperlink;}{\*\cs30 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\fs20\ul\cf0 \sbasedon10 \ssemihidden \styrsid3616458 FollowedHyperlink;}{
\s31\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af38\afs16\alang1025 \ltrch\fcs0 \fs16\lang2057\langfe2057\loch\f38\hich\af38\dbch\af31505\cgrid\langnp2057\langfenp2057
\sbasedon0 \snext31 \slink32 \ssemihidden \styrsid16393186 Balloon Text;}{\*\cs32 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \f38\fs16\lang0\langfe1033\langnp0\langfenp1033 \sbasedon10 \slink31 \slocked \ssemihidden Balloon Text Char;}{
\s33\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs24\alang1025 \ltrch\fcs0 \b\fs24\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057
\sbasedon0 \snext33 \spriority0 \styrsid1205517 Service Name;}{\*\cs34 \additive \f1\fs20\cf1 \spriority0 \styrsid13071565 Field Labels (10pt arial);}{
\s35\ql \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\contextualspace \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe2057\loch\f31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057
\sbasedon0 \snext35 \sqformat \spriority34 \styrsid3829546 List Paragraph;}{\s36\qc \li0\ri0\sb240\sa60\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs32\alang1025 \ltrch\fcs0
\b\fs32\lang2057\langfe2057\kerning28\loch\f31502\hich\af31502\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext0 \slink37 \sqformat \spriority10 \styrsid3829546 Title;}{\*\cs37 \additive \rtlch\fcs1 \ab\af0\afs32 \ltrch\fcs0
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\rtlch\fcs1 \af0 \ltrch\fcs0 \b\fs24\ul \sbasedon10 \sqformat \spriority32 \styrsid3829546 Intense Reference;}{\*\cs51 \additive \rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \b\i\f31502\fs24 \sbasedon10 \sqformat \spriority33 \styrsid3829546 Book Title;}{
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\spriority0 \styrsid6758744 Table Headers and Text;}{\*\ts54\tsrowd\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\spriority0 \styrsid1464804 Table labels;}{\*\cs56 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\fs20\cf1 \sbasedon10 \styrsid1464804 Table Labels;}{\*\ts57\tsrowd\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
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\fs24\lang2057\langfe2057\loch\f0\hich\af0\dbch\af31505\cgrid\langnp2057\langfenp2057 \sbasedon0 \snext58 \sunhideused \styrsid12461010 Normal (Web);}{\*\cs59 \additive \b\f1\fs20\cf1 \styrsid8144047 Table Headers + Text;}}{\*\listtable
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\f1\fs20\insrsid6243936\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 of }{\field{\*\fldinst {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid6243936\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 NUMPAGES \\* Arabic \\* MERGEFORMAT }
}{\fldrslt {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\f1\fs20\lang1024\langfe1024\noproof\insrsid1712829 \hich\af1\dbch\af31505\loch\f1 3}}}\sectd \ltrsect\linex0\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\fs20\insrsid13255093\charrsid5528926 \cell }\pard\plain \ltrpar\s42\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13255093 \rtlch\fcs1 \af0\afs32\alang1025 \ltrch\fcs0
\fs24\lang2057\langfe2057\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 {\*\bkmkstart PFo75UPz9HJ5rIy7gXRl}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900 {\*\datafield 00000000140000001450466f373555507a39484a35724979376758526c00000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname PFo75UPz9HJ5rIy7gXRl}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Title}}}\sectd \ltrsect
\linex0\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900 {\*\bkmkend PFo75UPz9HJ5rIy7gXRl}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\b\fs20\insrsid13255093\charrsid6243936 \cell }\pard \ltrpar\s42\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11668762 {\*\bkmkstart PkoHIVZ3jlZuYqXQCzh2}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900 {\*\datafield
000000001400000014506b6f4849565a336a6c5a7559715851437a683200000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname PkoHIVZ3jlZuYqXQCzh2}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 Given Name}}}\sectd \ltrsect\linex0\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid13255093\charrsid6243936 {\*\bkmkend PkoHIVZ3jlZuYqXQCzh2}\cell }\pard \ltrpar
\s42\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13255093 {\*\bkmkstart P5gIomjbO1bKnmiAf4hg}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900 {\*\datafield 000000001400000014503567496f6d6a624f31624b6e6d69416634686700000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname P5gIomjbO1bKnmiAf4hg}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid13255093\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Surname}}}\sectd \ltrsect
\linex0\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \b\fs20\insrsid13255093\charrsid6243936 {\*\bkmkend P5gIomjbO1bKnmiAf4hg}\cell }\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5528926 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe2057\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1
\af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid13255093\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Having a problem with this pro forma? Please email us at }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\cf2\insrsid13255093\charrsid16398400
\hich\af1\dbch\af31505\loch\f1 occg.gpproformas@nhs.net}{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid13255093\charrsid5528926 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1
\af0\afs20 \ltrch\fcs0 \fs20\insrsid13255093\charrsid5528926 \trowd \irow0\irowband0\ltrrow
\ts54\trgaph108\trrh270\trleft-108\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13255093\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmgf\clvertalc
\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth2093\clshdrawnil \cellx1847\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth1606\clshdrawnil
\cellx3356\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth1606\clshdrawnil \cellx4879\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl
\cltxlrtb\clftsWidth3\clwWidth1607\clshdrawnil \cellx6433\clvmgf\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth4302\clshdrawnil \cellx10574\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow
\ts54\trgaph108\trrh270\trleft-108\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5528926\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalc
\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth2093\clshdrawnil \cellx1847\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth2410\clshdrawnil
\cellx4128\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth2409\clshdrawnil \cellx6433\clvmrg\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl
\cltxlrtb\clftsWidth3\clwWidth4302\clshdrawnil \cellx10574\pard\plain \ltrpar\s42\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11668762 \rtlch\fcs1 \af0\afs32\alang1025 \ltrch\fcs0
\fs24\lang2057\langfe2057\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid5528926\charrsid5528926 \cell {\*\bkmkstart P4XfLwbq8pS6FSxO1XYj}}{\field\fldedit{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5528926\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5528926\charrsid16136900 {\*\datafield
000000001400000014503458664c776271387053364653784f3158596a00000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname P4XfLwbq8pS6FSxO1XYj}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid5528926\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 NHS Number}}}\sectd \ltrsect\linex0\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid5528926\charrsid5528926 {\*\bkmkend P4XfLwbq8pS6FSxO1XYj}\cell {\*\bkmkstart P9lGlJbxSZnvfdtaYzRS}}
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5528926\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5528926\charrsid16136900 {\*\datafield
00000000140000001450396c476c4a6278535a6e7666647461597a525300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname P9lGlJbxSZnvfdtaYzRS}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid5528926\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 Date of Birth}}}\sectd \ltrsect\linex0\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \fs20\insrsid5528926\charrsid5528926 {\*\bkmkend P9lGlJbxSZnvfdtaYzRS}\cell }{\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid5528926\charrsid16136900 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\fs24\lang2057\langfe2057\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid5528926\charrsid16136900 \trowd \irow1\irowband1\lastrow \ltrrow
\ts54\trgaph108\trrh270\trleft-108\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid5528926\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalc
\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth2093\clshdrawnil \cellx1847\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth2410\clshdrawnil
\cellx4128\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth3\clwWidth2409\clshdrawnil \cellx6433\clvmrg\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl
\cltxlrtb\clftsWidth3\clwWidth4302\clshdrawnil \cellx10574\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid6243936\charrsid16136900
\par }}{\footerf \ltrpar \pard\plain \ltrpar\s26\qc \li0\ri0\widctlpar\tqc\tx4153\tqr\tx8306\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5507611 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\fs24\lang2057\langfe2057\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \f1\fs16\insrsid5507611\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
Having a problem with this pro forma? Please email us at }{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \f1\fs16\insrsid7168009\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 OCCG.GPproformas@nhs.net}{\rtlch\fcs1 \af0 \ltrch\fcs0
\f1\insrsid5507611\charrsid16136900
\par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}
{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8
\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\ltrrow\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft-108\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16194513\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth2\clwWidth3103\clshdrawnil \cellx6521\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth2\clwWidth1897\clshdrawnil
\cellx10574\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8991751 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0
\fs24\lang2057\langfe2057\loch\af31506\hich\af31506\dbch\af31505\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af0\afs36 \ltrch\fcs0 \b\f1\fs32\insrsid8991751\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Adult Autism Diagnosis GP Referral Form
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1464804\charrsid1464804 \hich\af1\dbch\af31505\loch\f1 GP Pro Forma Oxfordshire}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid990616\charrsid5403614 \cell }\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8144047 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 v0.}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 3}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 EMIS }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15219296 \hich\af1\dbch\af31505\loch\f1 October}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid12335339 \hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 2018}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15213354\charrsid5403614
\par }\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15219296 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid990616\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 CRG approved }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 October }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15219296 \hich\af1\dbch\af31505\loch\f1 2018}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid990616\charrsid5403614 \cell
}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5403614\charrsid5403614 \trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft-108\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16194513\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth2\clwWidth3103\clshdrawnil \cellx6521\clvertalc\clbrdrt\brdrtbl \clbrdrl\brdrtbl \clbrdrb\brdrtbl \clbrdrr\brdrtbl \cltxlrtb\clftsWidth2\clwWidth1897\clshdrawnil
\cellx10574\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10639957 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid990616
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16136900 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 This is}{\rtlch\fcs1 \af0 \ltrch\fcs0
\b\f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 not}{\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 an urgent diagnostic service. If the patient is }{\rtlch\fcs1 \af0 \ltrch\fcs0
\b\f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 at significant risk of harm to self or others (including self-neglect\hich\af1\dbch\af31505\loch\f1 ) and/or has a current severe mental illness}{\rtlch\fcs1 \af0 \ltrch\fcs0
\b\f1\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 , refer to AMHT}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\insrsid16136900\charrsid16136900
\par
\par \hich\af1\dbch\af31505\loch\f1 All referrals must }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 have a completed AQ10 (included in}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 this form)
\par \hich\af1\dbch\af31505\loch\f1 Only refer those with Score >3 as otherwise highly unlikely to have significant ASD
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\par \hich\af1\dbch\af31505\loch\f1 Please make sure contact details are up to da\hich\af1\dbch\af31505\loch\f1 te
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16136900 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10902933 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid1712829 \hich\af1\dbch\af31505\loch\f1 All referrals }{\rtlch\fcs1 \af0 \ltrch\fcs0
\f1\insrsid10902933 \hich\af1\dbch\af31505\loch\f1 to }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\insrsid10902933\charrsid10902933 \hich\af1\dbch\af31505\loch\f1 OAADSS, }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\cf6\insrsid16136900\charrsid10902933
\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\insrsid10902933\charrsid10902933 \hich\af1\dbch\af31505\loch\f1 Autism at Kingwood, Baptist House,129 Broadway, Didcot, OX11 8XD}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\cf6\insrsid10902933
\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\cf6\insrsid16136900
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\insrsid1712829\charrsid1712829 \hich\af1\dbch\af31505\loch\f1 referral@kingwood.org.uk}{\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid1712829\charrsid1712829
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10639957 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid5403614
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth2229\clcbpatraw17 \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth2\clwWidth2771\clcbpatraw17 \cellx10632\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8144047 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f1\fs20\insrsid10358581\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Patient\hich\f1 \rquote \loch\f1 s details\cell \hich\af1\dbch\af31505\loch\f1 Patient\hich\f1 \rquote \loch\f1 s background and culture\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5403614\charrsid5403614 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth2229\clcbpatraw17 \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth2\clwWidth2771\clcbpatraw17 \cellx10632\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
\trbrdrv\brdrs\brdrw10 \trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth989\clshdrawnil \cellx6804\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1782\clshdrawnil \cellx10632\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1205517\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Forename\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957
{\*\bkmkstart P7ozJsYz7Nnin8gcaA5q}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722 {\*\datafield
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\hich\af1\dbch\af31505\loch\f1 Given Name}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722
{\*\bkmkend P7ozJsYz7Nnin8gcaA5q}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1205517\charrsid5403614 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1205517\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Ethnicity\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart PGbdGzZ9VcQT1tJRCAQu}{\*\bkmkstart Text5}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1126498
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1126498 {\*\datafield 00020000140000001450476264477a5a395663515431744a524341517500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname PGbdGzZ9VcQT1tJRCAQu}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1126498 \hich\af1\dbch\af31505\loch\f1 Ethnic Origin}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\*\bkmkend PGbdGzZ9VcQT1tJRCAQu}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8087477\charrsid5403614
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8087477\charrsid5403614 {\*\datafield 000000001400000005546578743500000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text5}}}}
}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8087477\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1205517\charrsid5403614
{\*\bkmkend Text5}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5403614\charrsid5403614 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth989\clshdrawnil \cellx6804\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1782\clshdrawnil \cellx10632\row \ltrrow}\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1205517\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Surname\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957
{\*\bkmkstart P7gZCxnAJRVa6NpPZd5c}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722 {\*\datafield
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\hich\af1\dbch\af31505\loch\f1 Surname}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722
{\*\bkmkend P7gZCxnAJRVa6NpPZd5c}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1205517\charrsid5403614 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1205517\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 1st }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid11877642\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 L}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1205517\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 anguage\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart PLpfjhA9ElGYgog8YKDs}{\*\bkmkstart Text6}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1126498
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1126498 {\*\datafield 000200001400000014504c70666a684139456c4759676f6738594b447300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname PLpfjhA9ElGYgog8YKDs}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1126498 \hich\af1\dbch\af31505\loch\f1 Main Language}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\*\bkmkend PLpfjhA9ElGYgog8YKDs}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8087477\charrsid5403614
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8087477\charrsid5403614 {\*\datafield 000000001400000005546578743600000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text6}}}}
}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8087477\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1205517\charrsid5403614
{\*\bkmkend Text6}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5403614\charrsid5403614 \trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth989\clshdrawnil \cellx6804\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1782\clshdrawnil \cellx10632\row \ltrrow}\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1205517\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Known as\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957
{\*\bkmkstart PhRm4a63OU4USmzlH6a7}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722 {\*\datafield
0002000014000000145068526d346136334f553455536d7a6c4836613700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PhRm4a63OU4USmzlH6a7}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722
\hich\af1\dbch\af31505\loch\f1 Calling Name}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid10436722
{\*\bkmkend PhRm4a63OU4USmzlH6a7}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid1205517\charrsid5403614 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3102417\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Interpreter required?}{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid1205517\charrsid5403614 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3102417\charrsid5403614
\hich\af1\dbch\af31505\loch\f1 Y }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3102417\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3102417\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3102417\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 N }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3102417\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3102417\charrsid5403614 {\*\datafield
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{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 {\*\datafield
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\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 {\*\bkmkend Pgbhcrn1zPDD8ijaQzkU}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1
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\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth667\clshdrawnil \cellx2698\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth323\clshdrawnil \cellx3392\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth598\clshdrawnil \cellx4679\clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth2\clwWidth2771\clcbpatraw17 \cellx10632\row \ltrrow}\trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
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\hich\af1\dbch\af31505\loch\f1 Sex\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart PPzp7qiTQZQqYQcvwhGV}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f1\fs20\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 {\*\datafield 00020000140000001450507a7037716954515a5171595163767768475600000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PPzp7qiTQZQqYQcvwhGV}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 Gender(full)}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 {\*\bkmkend PPzp7qiTQZQqYQcvwhGV}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400\charrsid5403614 \cell }\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid16398400\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Title\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\*\bkmkstart PkbwNToOn1XLjh4v4knP}
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 {\*\datafield
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\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16398400\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 NHS No\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801
{\*\bkmkstart P485vLYRyvtOcubuRWxn}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400 {\*\datafield
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\hich\af1\dbch\af31505\loch\f1 NHS Number}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400
{\*\bkmkend P485vLYRyvtOcubuRWxn}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid16398400\charrsid5403614 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1851739 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16398400\charrsid3282414 \hich\af1\dbch\af31505\loch\f1 Referrer\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1851739 {\*\bkmkstart Text9}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs16\cf18\insrsid16398400\charrsid3282414
\hich\af39\dbch\af31505\loch\f39 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs16\cf18\insrsid16398400\charrsid3282414 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9
}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs16\cf18\lang1024\langfe1024\noproof\insrsid16398400\charrsid3282414 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194
\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f39\fs16\cf18\insrsid16398400\charrsid3282414 {\*\bkmkend Text9}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16398400\charrsid5403614
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\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow}\trowd \irow7\irowband7\ltrrow\ts11\trgaph108\trrh422\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Address & Postcode\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957
{\*\bkmkstart PLqgj2cxFr5O5fmgDI4y}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield
000200001400000014504c71676a3263784672354f35666d674449347900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PLqgj2cxFr5O5fmgDI4y}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 Home Full Address (single line)}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
{\*\bkmkend PLqgj2cxFr5O5fmgDI4y}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 GP Address\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart ONhdLwdggD93W2cuzwMu}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield 0002000014000000144f4e68644c77646767443933573263757a774d7500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname ONhdLwdggD93W2cuzwMu}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Organisation Name}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\bkmkend ONhdLwdggD93W2cuzwMu}\hich\af1\dbch\af31505\loch\f1
\par {\*\bkmkstart O4o7AmcrCm4P6RFUIAWP}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield
0002000014000000144f346f37416d6372436d3450365246554941575000000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname O4o7AmcrCm4P6RFUIAWP}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 Organisation Full Address (single line)}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f1\fs20\insrsid8144047 {\*\bkmkend O4o7AmcrCm4P6RFUIAWP}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8144047\charrsid5403614 \trowd \irow7\irowband7\ltrrow\ts11\trgaph108\trrh422\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow}\trowd \irow8\irowband8\ltrrow\ts11\trgaph108\trrh53\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Hospital No\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801
{\*\bkmkstart PpQdaNUtJCaZlpfmHfEh}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield
00020000140000001450705164614e55744a43615a6c70666d4866456800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PpQdaNUtJCaZlpfmHfEh}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 Hospital Number}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
{\*\bkmkend PpQdaNUtJCaZlpfmHfEh}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 GP Tel No\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\*\bkmkstart OTEEaOCYd5f6vKdPh51u}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield 0002000014000000144f544545614f435964356636764b64506835317500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname OTEEaOCYd5f6vKdPh51u}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Organisation Telephone Number}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\bkmkend OTEEaOCYd5f6vKdPh51u}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8144047\charrsid5403614
\trowd \irow8\irowband8\ltrrow\ts11\trgaph108\trrh53\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow}\trowd \irow9\irowband9\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Email\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\*\bkmkstart PtIC53aIYf66cdkAffdI
}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield
00020000140000001450744943353361495966363663646b416666644900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PtIC53aIYf66cdkAffdI}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 Patient E-mail Address}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
{\*\bkmkend PtIC53aIYf66cdkAffdI}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Practice}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Email\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart OMKNxuoTcy6plp5vjHyg}
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield
0002000014000000144f4d4b4e78756f54637936706c7035766a48796700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname OMKNxuoTcy6plp5vjHyg}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 Organisation E-mail Address}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
{\*\bkmkend OMKNxuoTcy6plp5vjHyg}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8144047\charrsid5403614 \trowd \irow9\irowband9\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv
\brdrs\brdrw10 \trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth640\clshdrawnil \cellx1265\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1588\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow}\trowd \irow10\irowband10\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth1235\clcbpatraw17 \cellx2545\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth2\clwWidth480\clcbpatraw17 \cellx3577\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth513\clcbpatraw17 \cellx4679\clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth2771\clcbpatraw17 \cellx10632\pard \ltrpar\qc \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \cs59\b\f1\fs20\cf1\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Phone Numbers}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0
\cs59\b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid8144047 \cell }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \cs59\f1\fs16\cf1\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Preferred Number(s)}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0
\cs59\f1\fs16\cf1\lang2057\langfe1033\langfenp1033\insrsid8144047 \cell }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \cs59\f1\fs16\cf1\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Can leave messages?}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0
\cs59\f1\fs16\cf1\lang2057\langfe1033\langfenp1033\insrsid8144047 \cell }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \cs59\b\f1\fs20\cf1\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Referral Dates}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0
\cs59\b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid8144047 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3963700\charrsid5403614
\trowd \irow10\irowband10\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth1235\clcbpatraw17 \cellx2545\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth2\clwWidth480\clcbpatraw17 \cellx3577\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth513\clcbpatraw17 \cellx4679\clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth2771\clcbpatraw17 \cellx10632\row \ltrrow}\trowd \irow11\irowband11\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth378\clshdrawnil \cellx703\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth858\clshdrawnil \cellx2545\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth480\clshdrawnil \cellx3577\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth513\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Home}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid8144047\charrsid5403614 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart PNmBpHqJxBpmktgueBh4}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield 000200001400000014504e6d427048714a7842706d6b7467756542683400000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PNmBpHqJxBpmktgueBh4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Patient Home Telephone}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 {\*\bkmkend PNmBpHqJxBpmktgueBh4}\cell }\pard \ltrpar
\qc \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid8144047 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047
\hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \cell }\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15213354 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Referral }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Date\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart diyj2nPp5WTcKrSDIiJt}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield 0002000014000000146469796a326e5070355754634b72534449694a7400000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname diyj2nPp5WTcKrSDIiJt}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Short date letter\hich\af1\dbch\af31505\loch\f1 merged}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\bkmkend diyj2nPp5WTcKrSDIiJt}\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1251540\charrsid5403614
\trowd \irow11\irowband11\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth378\clshdrawnil \cellx703\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth858\clshdrawnil \cellx2545\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth480\clshdrawnil \cellx3577\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth513\clshdrawnil \cellx4679\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow
}\trowd \irow12\irowband12\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth378\clshdrawnil \cellx703\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth858\clshdrawnil \cellx2545\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth480\clshdrawnil \cellx3577\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth513\clshdrawnil \cellx4679\clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Work\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart P6KTkaWQyXZxpSAMkmK3}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield 00020000140000001450364b546b61575179585a787053414d6b6d4b3300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname P6KTkaWQyXZxpSAMkmK3}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Patient Work Telephone}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 {\*\bkmkend P6KTkaWQyXZxpSAMkmK3}\cell }\pard \ltrpar
\qc \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid5439801 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047
\hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \cell }\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Date received\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart Text4}{\field\flddirty{\*\fldinst
{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid8144047\charrsid14885609 \hich\af39\dbch\af31505\loch\f39 FORMTEXT }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid8144047\charrsid14885609 {\*\datafield
000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid8144047\charrsid14885609 \loch\af39\dbch\af31505\hich\f39 \u8194\'20
\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid8144047\charrsid14885609 {\*\bkmkend Text4}\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1251540\charrsid5403614 \trowd \irow12\irowband12\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth378\clshdrawnil \cellx703\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth858\clshdrawnil \cellx2545\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth480\clshdrawnil \cellx3577\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth513\clshdrawnil \cellx4679\clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow
}\trowd \irow13\irowband13\ltrrow\ts11\trgaph108\trrh268\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth378\clshdrawnil \cellx703\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth858\clshdrawnil \cellx2545\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth480\clshdrawnil \cellx3577\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth513\clshdrawnil \cellx4679\clvmrg\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvmrg\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4944818 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8144047\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Mobile\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\*\bkmkstart PmQtcTcrvFunXGQnkS5D}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047
\hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 {\*\datafield 000200001400000014506d5174635463727646756e5847516e6b53354400000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname PmQtcTcrvFunXGQnkS5D}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047 \hich\af1\dbch\af31505\loch\f1 Patient Mobile Telephone}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8144047\charrsid5403614 {\*\bkmkend PmQtcTcrvFunXGQnkS5D}\cell }\pard \ltrpar
\qc \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid5439801 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \cell }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047
\hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid8144047\charrsid8144047 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\insrsid8144047\charrsid5403614 \cell \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1251540\charrsid5403614 \trowd \irow13\irowband13\ltrrow
\ts11\trgaph108\trrh268\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth378\clshdrawnil \cellx703\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth858\clshdrawnil \cellx2545\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth480\clshdrawnil \cellx3577\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth513\clshdrawnil \cellx4679\clvmrg\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth727\clshdrawnil \cellx6241\clvmrg\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow
}\trowd \irow14\irowband14\ltrrow\ts11\trgaph108\trrh546\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw17 \cellx10632\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3963700 {
\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \cs59\b\f1\fs20\cf1\insrsid3963700\charrsid3963700 \hich\af1\dbch\af31505\loch\f1 Additional contact details\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3963700\charrsid5403614 \trowd \irow14\irowband14\ltrrow\ts11\trgaph108\trrh546\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv
\brdrs\brdrw10 \trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw17 \cellx10632\row \ltrrow}\trowd \irow15\irowband15\ltrrow\ts11\trgaph108\trrh402\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1500\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar
\qc \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid5439801 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\cf6\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
The preferred form of contact is by email so that forms can be sent prior to appointment\cell }\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \hich\af1\dbch\af31505\loch\f1 Use email address above\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Y }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 N }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield
650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7930909\charrsid5403614 \trowd \irow15\irowband15\ltrrow\ts11\trgaph108\trrh402\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1500\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow
}\trowd \irow16\irowband16\ltrrow\ts11\trgaph108\trrh408\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1500\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\pard \ltrpar
\qc \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid5439801 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700 \hich\af1\dbch\af31505\loch\f1 Use alternative email address
}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 Y }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 N }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield
650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700 \hich\af1\dbch\af31505\loch\f1 S\hich\af1\dbch\af31505\loch\f1 pecify: }
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield
000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3963700\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7930909\charrsid5403614 \trowd \irow16\irowband16\ltrrow\ts11\trgaph108\trrh408\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1500\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2044\clshdrawnil \cellx10632\row \ltrrow
}\trowd \irow17\irowband17\ltrrow\ts11\trgaph108\trrh268\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth374\clshdrawnil \cellx3820\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1126\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth462\clshdrawnil \cellx7234\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1582\clshdrawnil \cellx10632\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700 \hich\af1\dbch\af31505\loch\f1 S}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \hich\af1\dbch\af31505\loch\f1
ignificant friends/relatives who }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid7930909 \hich\af1\dbch\af31505\loch\f1 patient agrees }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid7930909 \hich\af1\dbch\af31505\loch\f1 may}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \hich\af1\dbch\af31505\loch\f1
be contacted if patient cannot be contacted\cell }\pard \ltrpar\qr \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700
\hich\af1\dbch\af31505\loch\f1 Name}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid8144047 \cell }\pard \ltrpar\ql \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3430508
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield
000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid8144047 \cell }\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \hich\af1\dbch\af31505\loch\f1 Phone\cell
}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1
FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194
\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \cell
}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3963700\charrsid5403614 \trowd \irow17\irowband17\ltrrow\ts11\trgaph108\trrh268\trleft-108\trbrdrt\brdrs\brdrw10
\trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmgf\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth374\clshdrawnil \cellx3820\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1126\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth462\clshdrawnil \cellx7234\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1582\clshdrawnil \cellx10632\row \ltrrow}\trowd \irow18\irowband18\ltrrow\ts11\trgaph108\trrh268\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
\trbrdrv\brdrs\brdrw10 \trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth374\clshdrawnil \cellx3820\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1126\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth462\clshdrawnil \cellx7234\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1582\clshdrawnil \cellx10632\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700 \cell
}\pard \ltrpar\qr \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700 \hich\af1\dbch\af31505\loch\f1 Name}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid8144047 \cell }\pard \ltrpar\ql \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3430508 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield 000000001400000005546578743400000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid8144047 \cell }\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \hich\af1\dbch\af31505\loch\f1 Phone\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield
000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3963700\charrsid5403614 \trowd \irow18\irowband18\ltrrow\ts11\trgaph108\trrh268\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth374\clshdrawnil \cellx3820\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1126\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth462\clshdrawnil \cellx7234\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1582\clshdrawnil \cellx10632\row \ltrrow}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10639957 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700 \cell
}\pard \ltrpar\qr \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700 \hich\af1\dbch\af31505\loch\f1 Name}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid8144047 \cell }\pard \ltrpar\ql \li0\ri0\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3430508 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield 000000001400000005546578743400000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid8144047 \cell }\pard \ltrpar\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3963700 {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \hich\af1\dbch\af31505\loch\f1 Phone\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 {\*\datafield
000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid3963700\charrsid5403614 \loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid3963700\charrsid3963700 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3963700\charrsid5403614 \trowd \irow19\irowband19\lastrow \ltrrow\ts11\trgaph108\trrh268\trleft-108\trbrdrt\brdrs\brdrw10
\trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5027\trftsWidthB3\trftsWidthA3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16398400\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvmrg\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1455\clshdrawnil \cellx3016\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth374\clshdrawnil \cellx3820\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1126\clshdrawnil \cellx6241\clvertalc\clbrdrt\brdrs\brdrw10
\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth462\clshdrawnil \cellx7234\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth2\clwWidth1582\clshdrawnil \cellx10632\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10639957 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid11862480\charrsid3430508
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts54\trqc\trgaph108\trrh655\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3430508\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth10682\clcbpatraw17 \cellx10574\pard \ltrpar\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1
\ltrch\fcs0 \b\f1\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 Risk assessment
\par }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \b\f1\fs22\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 Please note}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1
if any significant risk then needs to be sent to AMHT }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \b\f1\fs22\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 not}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3430508\charrsid3430508
\hich\af1\dbch\af31505\loch\f1 the autism diagnostic service\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid3430508 \trowd \irow0\irowband0\ltrrow
\ts54\trqc\trgaph108\trrh655\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3430508\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth10682\clcbpatraw17 \cellx10574\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts54\trqc\trgaph108\trrh394\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14106338\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth4361\clcbpatraw17 \cellx4253\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth3\clwWidth6321\clcbpatraw17 \cellx10574\pard \ltrpar\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid3430508 \cell
}\pard \ltrpar\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 Your assessment\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid3430508 \trowd \irow1\irowband1\ltrrow\ts54\trqc\trgaph108\trrh394\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14106338\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth4361\clcbpatraw17 \cellx4253\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth3\clwWidth6321\clcbpatraw17 \cellx10574\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid1067137\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1276\clshdrawnil \cellx4253\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6321\clshdrawnil \cellx10574\pard \ltrpar
\qr \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 Risk of harm to self\cell }\pard \ltrpar
\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 N}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 Y}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 \hich\af39\dbch\af31505\loch\f39
FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 {\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20
\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid3430508\charrsid3430508 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid3430508 \trowd \irow2\irowband2\ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid1067137\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1276\clshdrawnil \cellx4253
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6321\clshdrawnil \cellx10574\row \ltrrow}\pard \ltrpar
\qr \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 Risk of harm to others\cell
}\pard \ltrpar\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 N}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 Y}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 \hich\af39\dbch\af31505\loch\f39
FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 {\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20
\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid3430508\charrsid3430508 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid3430508 \trowd \irow3\irowband3\ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid1067137\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1276\clshdrawnil \cellx4253
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6321\clshdrawnil \cellx10574\row \ltrrow}\pard \ltrpar
\qr \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 Evidence of }{\rtlch\fcs1 \af1\afs22
\ltrch\fcs0 \f1\fs22\insrsid16136900\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 self-neglect}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3430508\charrsid3430508 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 N}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 Y}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 \hich\af39\dbch\af31505\loch\f39
FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 {\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20
\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid3430508\charrsid3430508 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid3430508 \trowd \irow4\irowband4\ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid1067137\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1276\clshdrawnil \cellx4253
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6321\clshdrawnil \cellx10574\row \ltrrow}\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 Vulnerable adult\cell }\pard \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 N}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 Y}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid3430508\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 \hich\af39\dbch\af31505\loch\f39 FORMTEXT }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid3430508\charrsid3430508 {\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f39\fs20\insrsid3430508\charrsid3430508 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194
\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid3430508\charrsid3430508 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid3430508 \trowd \irow5\irowband5\ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid1067137\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1276\clshdrawnil \cellx4253
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6321\clshdrawnil \cellx10574\row \ltrrow}\pard \ltrpar
\qr \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3430508 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid1067137 \hich\af1\dbch\af31505\loch\f1 Risk of drugs / }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0
\f1\fs22\insrsid1067137\charrsid1067137 \hich\af1\dbch\af31505\loch\f1 alcohol not included elsewhere}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid1067137 ,}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid1067137\charrsid1067137
\hich\af1\dbch\af31505\loch\f1 if known}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid1067137\charrsid3430508 \cell }\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1067137 \hich\af1\dbch\af31505\loch\f1 N}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1067137\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid1067137\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1067137\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid1067137 \hich\af1\dbch\af31505\loch\f1 Y}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1067137\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid1067137\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1067137\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid1067137\charrsid5403614 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5439801 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f39\fs20\insrsid1067137\charrsid3430508 \hich\af39\dbch\af31505\loch\f39 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid1067137\charrsid3430508 {\*\datafield 000000001400000005546578743400000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid1067137\charrsid3430508 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20
\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {
\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid1067137\charrsid3430508 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid1067137
\trowd \irow6\irowband6\lastrow \ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid1067137\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3085\clshdrawnil \cellx2977\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1276\clshdrawnil \cellx4253
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6321\clshdrawnil \cellx10574\row }\pard \ltrpar
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6510927 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid6510927
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid1067137
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trqc\trgaph113\trrh865\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth10692\clcbpatraw17 \cellx10584\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16136900 {\rtlch\fcs1 \ab\af1\afs28
\ltrch\fcs0 \b\f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Autism Spectrum Quotient (AQ-10)}{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\insrsid16136900
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\cf6\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Referral will be rejected if not completed}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\cf6\insrsid16136900
\par }\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid15219296 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15219296\charrsid15219296 \hich\af31506\dbch\af31505\loch\f31506 Printable version:}{\rtlch\fcs1 \af1 \ltrch\fcs0
\b\f1\cf6\insrsid15219296 \hich\af1\dbch\af31505\loch\f1 }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\cf6\insrsid15219296 \hich\af1\dbch\af31505\loch\f1 HYPERLINK "https://occg.info/AQ10" }{\rtlch\fcs1 \af1 \ltrch\fcs0
\b\f1\cf6\insrsid15219296 {\*\datafield
00d0c9ea79f9bace118c8200aa004ba90b0200000003000000e0c9ea79f9bace118c8200aa004ba90b46000000680074007400700073003a002f002f006f006300630067002e0069006e0066006f002f0041005100310030000000795881f43b1d7f48af2c825dc485276300000000a5ab00000600003400}}}{\fldrslt
{\*\bkmkstart Text10}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \cs29\b\f1\ul\cf2\insrsid15219296\charrsid15219296 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \cs29\b\f1\ul\cf2\insrsid15219296\charrsid15219296
{\*\datafield 00000000140000000654657874313000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text10}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs29\ul\cf2\insrsid15219296 \hich\af31506\dbch\af31505\loch\f31506 Ctrl-Click }{
\rtlch\fcs1 \af0 \ltrch\fcs0 \cs29\ul\cf2\insrsid15219296\charrsid15219296 \hich\af31506\dbch\af31505\loch\f31506 occg.info/AQ10}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj
{\*\bkmkend Text10}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\cf6\insrsid15219296\charrsid16136900 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow0\irowband0\ltrrow\ts11\trqc\trgaph113\trrh865\trleft-108\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth10692\clcbpatraw17 \cellx10584\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trqc\trgaph113\trrh308\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth680\clcbpatraw17 \cellx572\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat17\cltxlrtb\clftsWidth3\clwWidth5529\clcbpatraw17\clhidemark \cellx6101\clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw17\clhidemark
\cellx7221\clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw17\clhidemark \cellx8342\clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb
\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw17\clhidemark \cellx9463\clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw17\clhidemark \cellx10584\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li60\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin60\pararsid16136900 {\rtlch\fcs1 \ab\ai\af1 \ltrch\fcs0 \b\f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 Please tick one option per question only}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \b\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs18\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Definitely agree}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0
\b\f1\fs18\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs18\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Slightly agree}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0
\b\f1\fs18\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs18\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Slightly disagree}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0
\b\f1\fs18\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs18\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Definitely disagree}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0
\b\f1\fs18\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow1\irowband1\ltrrow\ts11\trqc\trgaph113\trrh308\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth680\clcbpatraw17 \cellx572\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat17\cltxlrtb\clftsWidth3\clwWidth5529\clcbpatraw17\clhidemark \cellx6101\clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw17\clhidemark
\cellx7221\clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw17\clhidemark \cellx8342\clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb
\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw17\clhidemark \cellx9463\clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw17\clhidemark \cellx10584\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trqc\trgaph113\trrh23\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
\trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw19 \cellx7221\clvertalc
\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr
\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx10584\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 1}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li60\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin60\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I often notice small sounds when others do not}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow2\irowband2\ltrrow\ts11\trqc\trgaph113\trrh23\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw19 \cellx7221\clvertalc
\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr
\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx10584\row \ltrrow
}\trowd \irow3\irowband3\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1120\clshdrawnil \cellx7221\clvertalc\clbrdrt
\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx10584\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 2}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li60\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin60\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I usually concentrate more on the whole picture, rather than the small details}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000006436865636b3800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check8}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check10}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow3\irowband3\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1120\clshdrawnil \cellx7221\clvertalc\clbrdrt
\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx10584\row \ltrrow
}\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 3}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I find it easy to do more than one thing at once}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check11}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check12}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check13}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check14}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow4\irowband4\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1120\clshdrawnil \cellx7221\clvertalc\clbrdrt
\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx10584\row \ltrrow
}\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 4}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li60\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin60\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 If there is an interruption, I can switch back to wh\hich\af1\dbch\af31505\loch\f1 at I was doing very quickly}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell
}\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check15}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check16}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check17}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b313800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check18}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow5\irowband5\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1120\clshdrawnil \cellx7221\clvertalc\clbrdrt
\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx10584\row \ltrrow
}\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 5}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li60\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin60\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I find it easy to \hich\f1 \lquote \loch\f1 read between the lines\hich\f1 \rquote \loch\f1 when someone is talking to me}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield
650000001400000007436865636b313900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check19}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900
{\*\datafield 650000001400000007436865636b333900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check39}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900
{\*\datafield 650000001400000007436865636b343000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check40}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900
{\*\datafield 650000001400000007436865636b343100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check41}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow6\irowband6\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10
\trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1120\clshdrawnil \cellx7221\clvertalc\clbrdrt
\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx10584\row \ltrrow
}\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 6}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li60\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin60\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I know how to tell if someone listening to me is getting bored}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check20}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check34}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check35}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check38}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow7\irowband7\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1120\clshdrawnil \cellx7221\clvertalc\clbrdrt
\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx10584\row \ltrrow
}\trowd \irow8\irowband8\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw19 \cellx7221\clvertalc
\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr
\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx10584\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 7}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li60\ri0\sl-268\slmult0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin60\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 When I\hich\f1 \rquote \loch\f1 m reading a story}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900 ,}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I find it difficult to work out the characters\hich\f1 \rquote \loch\f1 intentions}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check21}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check33}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check36}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check37}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow8\irowband8\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw19 \cellx7221\clvertalc
\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr
\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx10584\row \ltrrow
}\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 8}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li40\ri194\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin194\lin40\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I like to collect information about categories of things (e.g. types of car, bird, train, plant etc.)}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell
}\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323200000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check22}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check30}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check31}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b333200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check32}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow9\irowband9\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw19 \cellx7221\clvertalc
\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr
\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx10584\row \ltrrow
}\trowd \irow10\irowband10\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1120\clshdrawnil \cellx7221\clvertalc\clbrdrt
\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx10584\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 9}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I find it easy to work out what someone is thinking or feeling just by looking at their face}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check23}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check29}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323800000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check28}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check27}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow10\irowband10\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1120\clshdrawnil \cellx7221\clvertalc\clbrdrt
\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx10584\row \ltrrow
}\trowd \irow11\irowband11\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw19 \cellx7221\clvertalc
\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr
\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx10584\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\charscalex97\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 10}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar\qr \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 I find it difficult to work out people\hich\f1 \rquote \loch\f1 s intentions}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid3677206 {\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check24}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check25}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check26}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16398400 \cell }{\field\fldedit\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1
FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 {\*\datafield 650000001400000007436865636b323700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check27}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs36\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow11\irowband11\ltrrow\ts11\trqc\trgaph113\trrh17\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth680\clshdrawnil\clhidemark \cellx572\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15
\cltxlrtb\clftsWidth3\clwWidth5529\clshdrawnil\clhidemark \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1120\clcbpatraw19 \cellx7221\clvertalc
\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat19\cltxlrtb\clftsWidth3\clwWidth1121\clcbpatraw19 \cellx8342\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr
\brdrs\brdrw15 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx9463\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1121\clshdrawnil \cellx10584\row \ltrrow
}\trowd \irow12\irowband12\ltrrow\ts11\trqc\trgaph113\trrh597\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth10692\clcbpatraw17 \cellx10584\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16136900 {\rtlch\fcs1 \ab\af1
\ltrch\fcs0 \b\f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 SCORING:}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid16136900
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Only 1 point can be scored for each question}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16136900
\par }{\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Score 1 point for each }{\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 answer above that is }{\rtlch\fcs1 \ai\af1
\ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 in a}{\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 n}{\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900
\hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\chshdng0\chcfpat0\chcbpat20\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 Amber}{\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 }{
\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\insrsid16136900\charrsid16136900 \hich\af1\dbch\af31505\loch\f1 box}{\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\insrsid16136900
\par }{\rtlch\fcs1 \ai\af1 \ltrch\fcs0 \f1\insrsid16656320
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16656320 \hich\af1\dbch\af31505\loch\f1 Only refer patients with a score of 3 or more
\par }\pard \ltrpar\qc \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16656320 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid16656320\charrsid16656320 \hich\af1\dbch\af31505\loch\f1 (NB }{\rtlch\fcs1
\af1 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid11100304\charrsid11100304 \hich\af1\dbch\af31505\loch\f1 Oxfordshire patients can be seen with a lower score than that recommended by NICE}{\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid16656320\charrsid16656320 \hich\af1\dbch\af31505\loch\f1 )}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16656320\charrsid16136900 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid16136900 \trowd \irow12\irowband12\ltrrow\ts11\trqc\trgaph113\trrh597\trleft-108\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16136900\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth10692\clcbpatraw17 \cellx10584\row \ltrrow}\trowd \irow13\irowband13\ltrrow\ts11\trqc\trgaph113\trrh386\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth6209\clcbpatraw17 \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth4483\clcbpatraw21 \cellx10584\pard \ltrpar\qr \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16136900 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid16136900 \hich\af1\dbch\af31505\loch\f1
Final Score}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid16136900\charrsid16136900 \cell }\pard \ltrpar\ql \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16136900 {\*\bkmkstart Text8}{\field{\*\fldinst {\rtlch\fcs1 \ab\af1
\ltrch\fcs0 \b\f1\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid16136900 {\*\datafield 000000001400000005546578743800000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname
Text8}}}}}{\fldrslt {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\lang1024\langfe1024\noproof\insrsid16136900 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af1 \ltrch\fcs0
\b\f1\insrsid16136900\charrsid16136900 {\*\bkmkend Text8}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid16136900
\trowd \irow13\irowband13\ltrrow\ts11\trqc\trgaph113\trrh386\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth6209\clcbpatraw17 \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw15 \clbrdrr\brdrs\brdrw10
\clcbpat21\cltxlrtb\clftsWidth3\clwWidth4483\clcbpatraw21 \cellx10584\row \ltrrow}\trowd \irow14\irowband14\lastrow \ltrrow\ts11\trqc\trgaph113\trrh210\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10
\trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth6209\clcbpatraw17 \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth4483\clshdrawnil \cellx10584\pard \ltrpar\qr \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid15219296 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \f1\fs22\insrsid15219296\charrsid15219296
\hich\af1\dbch\af31505\loch\f1 I am }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \f1\fs22\insrsid15219296 \hich\af1\dbch\af31505\loch\f1 sending}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \f1\fs22\insrsid15219296\charrsid15219296 \hich\af1\dbch\af31505\loch\f1 a }{
\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \f1\fs22\insrsid15219296 \hich\af1\dbch\af31505\loch\f1 separate, }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \f1\fs22\insrsid11100304 \hich\af1\dbch\af31505\loch\f1 printed AQ10}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0
\f1\fs22\insrsid15219296\charrsid15219296 \hich\af1\dbch\af31505\loch\f1 }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \f1\fs22\insrsid15219296 \hich\af1\dbch\af31505\loch\f1 as an attachment}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0
\f1\fs22\insrsid15219296\charrsid15219296 \cell }\pard \ltrpar\ql \li0\ri0\keepn\nowidctlpar\intbl\wrapdefault\faauto\rin0\lin0\pararsid16136900 {\*\bkmkstart Check42}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \ab\af1 \ltrch\fcs0
\b\f1\insrsid15219296 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid15219296 {\*\datafield 650000001400000007436865636b343200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check42}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid15219296 {\*\bkmkend Check42}\cell
}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f1\fs20\insrsid15219296\charrsid16136900 \trowd \irow14\irowband14\lastrow \ltrrow
\ts11\trqc\trgaph113\trrh210\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw15 \trbrdrv\brdrs\brdrw15
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trpaddl113\trpaddt113\trpaddb113\trpaddr113\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15219296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind5\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw15 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth6209\clcbpatraw17 \cellx6101\clvertalc\clbrdrt\brdrs\brdrw15 \clbrdrl\brdrs\brdrw15 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth4483\clshdrawnil \cellx10584\row }\pard \ltrpar\ql \li0\ri0\sl-72\slmult0\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid16136900\charrsid16136900
\par }\pard \ltrpar\ql \li0\ri0\keepn\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid16136900 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid16136900\charrsid16136900
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6510927 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid16136900
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts54\trqc\trgaph108\trrh655\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3677206\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth10682\clcbpatraw17 \cellx10574\pard \ltrpar\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1
\ltrch\fcs0 \b\f1\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 Family / social context}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid16136900\charrsid1067137 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid16136900\charrsid1067137 \trowd \irow0\irowband0\ltrrow\ts54\trqc\trgaph108\trrh655\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3677206\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth10682\clcbpatraw17 \cellx10574\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3677206\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3369\clshdrawnil \cellx3261\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1275\clshdrawnil \cellx4536
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6038\clshdrawnil \cellx10574\pard \ltrpar
\qr \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 A}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0
\f1\fs22\insrsid16136900\charrsid1067137 \hich\af1\dbch\af31505\loch\f1 ny }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3282414 \hich\af1\dbch\af31505\loch\f1 under }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid16136900\charrsid1067137
\hich\af1\dbch\af31505\loch\f1 18}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid3282414 \hich\af1\dbch\af31505\loch\f1 s in the family}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid16136900\charrsid3430508 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 N}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 Y}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3677206 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid16136900\charrsid3430508 \hich\af39\dbch\af31505\loch\f39
FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid16136900\charrsid3430508 {\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid16136900\charrsid3430508 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20
\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid16136900\charrsid3430508 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid16136900\charrsid3430508 \trowd \irow1\irowband1\ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3677206\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3369\clshdrawnil \cellx3261\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1275\clshdrawnil \cellx4536
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6038\clshdrawnil \cellx10574\row \ltrrow}\pard \ltrpar
\qr \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 P}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0
\f1\fs22\insrsid16136900\charrsid1067137 \hich\af1\dbch\af31505\loch\f1 regnant or has a baby < 1year}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid16136900\charrsid3430508 \cell }\pard \ltrpar
\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3677206 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 N}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900 \hich\af1\dbch\af31505\loch\f1 Y}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid16136900\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid16136900\charrsid5403614 \cell }\pard \ltrpar
\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3677206 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid16136900\charrsid3430508 \hich\af39\dbch\af31505\loch\f39
FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid16136900\charrsid3430508 {\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f39\fs20\insrsid16136900\charrsid3430508 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20
\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid16136900\charrsid3430508 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f39\insrsid16136900\charrsid3430508 \trowd \irow2\irowband2\lastrow \ltrrow\ts54\trqc\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3677206\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3369\clshdrawnil \cellx3261\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1275\clshdrawnil \cellx4536
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6038\clshdrawnil \cellx10574\row }\pard \ltrpar
\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6510927 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid1067137
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trrh2400\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3282414\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10682\clcbpatraw22 \cellx10574\pard \ltrpar\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1251540 {\rtlch\fcs1 \af0\afs28 \ltrch\fcs0
\b\f1\fs28\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \hich\af1\dbch\af31505\loch\f1 Referral narrative / Reason for referral
\par }{\rtlch\fcs1 \af0\afs28 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540
\par }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 Please i}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540
\hich\af1\dbch\af31505\loch\f1 nc}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 lude}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \hich\af1\dbch\af31505\loch\f1 :
\par {\listtext\pard\plain\ltrpar \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f3\fs22\lang2057\langfe1033\langfenp1033\insrsid9919470 \loch\af3\dbch\af31505\hich\f3 \'b7\tab}}\pard \ltrpar
\ql \fi-360\li720\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls7\adjustright\rin0\lin720\pararsid3430508 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid9919470 \hich\af1\dbch\af31505\loch\f1
Significant family or social issues
\par {\listtext\pard\plain\ltrpar \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f3\fs22\lang2057\langfe1033\langfenp1033\insrsid9919470\charrsid9919470 \loch\af3\dbch\af31505\hich\f3 \'b7\tab}}\pard \ltrpar
\ql \fi-360\li720\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls7\adjustright\rin0\lin720\pararsid6978368 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid9919470\charrsid9919470
\hich\af1\dbch\af31505\loch\f1 Relevant people involved in the patient}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid14885609 \loch\af1\dbch\af31505\hich\f1 \rquote }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid9919470\charrsid9919470 \hich\af1\dbch\af31505\loch\f1 s care
\par {\listtext\pard\plain\ltrpar \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f3\fs22\lang2057\langfe1033\langfenp1033\insrsid14885609 \loch\af3\dbch\af31505\hich\f3 \'b7\tab}}\pard \ltrpar
\ql \fi-360\li720\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls7\adjustright\rin0\lin720\pararsid3430508 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid14885609 \hich\af1\dbch\af31505\loch\f1 A}{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1
ny indications / problems the patient is experiencing, e.g. repeated / longstanding issues in personal and work relationships, sensory issues that impact on everyday ta\hich\af1\dbch\af31505\loch\f1 sks and activities}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540
\par {\listtext\pard\plain\ltrpar \intbl\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f3\fs22\lang2057\langfe1033\langfenp1033\insrsid14885609 \loch\af3\dbch\af31505\hich\f3 \'b7\tab}}\pard \ltrpar
\ql \fi-360\li720\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\ls7\adjustright\rin0\lin720\pararsid1251540 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid14885609 \hich\af1\dbch\af31505\loch\f1 A}{
\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 ny significant MH issues not recorded in problem list}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508 ,}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 if known}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0
\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508 \line \hich\af1\dbch\af31505\loch\f1 (}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508\charrsid3430508 \hich\af1\dbch\af31505\loch\f1 If }{\rtlch\fcs1
\af0\afs22 \ltrch\fcs0 \b\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 there are }{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508\charrsid3430508
\hich\af1\dbch\af31505\loch\f1 any current ongoing significant MH issues then refer to AMHT}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \b\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid3430508 \hich\af1\dbch\af31505\loch\f1 )}{\rtlch\fcs1 \af0\afs22
\ltrch\fcs0 \b\f1\fs22\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540
\par }\pard \ltrpar\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1251540 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1251540\charrsid1251540 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trrh2400\trleft-108\trkeep\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3282414\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10682\clcbpatraw22 \cellx10574\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth2\trwWidth5000\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3282414\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth877\clshdrawnil\clhidemark \cellx769\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth9805\clcbpatraw22\clhidemark \cellx10574\pard \ltrpar\qc \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1251540 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af0
\ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 {\*\datafield
650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\fs22\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \cell }\pard \ltrpar
\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1251540 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \hich\af1\dbch\af31505\loch\f1
Please tick here if you are sending any additional documents}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \hich\af1\dbch\af31505\loch\f1 The referral narrative should be typed below, not in a separate letter}{\rtlch\fcs1 \af0 \ltrch\fcs0
\b\f1\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1251540\charrsid1251540
\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3282414\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth877\clshdrawnil\clhidemark \cellx769\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth9805\clcbpatraw22\clhidemark \cellx10574\row \ltrrow}\trowd \irow2\irowband2\lastrow \ltrrow\ts11\trgaph108\trrh2071\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth2\trwWidth5000\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3282414\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth10682\clshdrawnil\clhidemark \cellx10574\pard \ltrpar
\ql \li0\ri0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1251540 {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f39\cf18\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540
\hich\af39\dbch\af31505\loch\f39 FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f39\cf18\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 {\*\datafield 000000001400000005546578743100000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text1}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f39\cf18\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39
\u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20\loch\af39\dbch\af31505\hich\f39 \u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\f39\cf18\lang2057\langfe1033\langfenp1033\insrsid1251540\charrsid1251540 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid1251540\charrsid1251540 \trowd \irow2\irowband2\lastrow \ltrrow\ts11\trgaph108\trrh2071\trleft-108\trkeep\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3282414\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth10682\clshdrawnil\clhidemark \cellx10574\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10639957 {\rtlch\fcs1 \af1 \ltrch\fcs0
\b\f1\insrsid5046627
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid14885609\charrsid2904801
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trrh460\trleft-108\trkeep\trhdr\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw17\clhidemark \cellx10574\pard \ltrpar\qc \li0\ri0\sl276\slmult1\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1
\ab\af0 \ltrch\fcs0 \b\f1\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Additional Patient Information\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \f37\fs20\insrsid14885609\charrsid14885609 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trrh460\trleft-108\trkeep\trhdr\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw17\clhidemark \cellx10574\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trrh323\trleft-108\trkeep\trhdr\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth680\clcbpatraw17 \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth2\clwWidth2024\clcbpatraw17\clhidemark \cellx5669\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth2296\clcbpatraw17\clhidemark
\cellx10574\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs22\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609
\cell }\pard \ltrpar\qc \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609
\hich\af1\dbch\af31505\loch\f1 Coded results\cell \hich\af1\dbch\af31505\loch\f1 Manually entered if not autopopulated\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20
\ltrch\fcs0 \f37\fs20\insrsid14885609\charrsid14885609 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trrh323\trleft-108\trkeep\trhdr\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv
\brdrs\brdrw10 \trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth680\clcbpatraw17 \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\clcbpat17\cltxlrtb\clftsWidth2\clwWidth2024\clcbpatraw17\clhidemark \cellx5669\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth2\clwWidth2296\clcbpatraw17\clhidemark
\cellx10574\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574\pard \ltrpar\qr \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Height\cell
}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\*\bkmkstart TY9JWb66YfDmEMRSSrjs}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield
0002000014000000145459394a576236365966446d454d525353726a7300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TY9JWb66YfDmEMRSSrjs}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Height}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0
\b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\bkmkend TY9JWb66YfDmEMRSSrjs}\cell }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609
\hich\af1\dbch\af31505\loch\f1 Date & Result: }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \ab\af0
\ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\datafield 00000000140000000654657874323900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text29}}}}}{\fldrslt {\rtlch\fcs1
\ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang1024\langfe1024\noproof\langfenp1033\insrsid14885609\charrsid14885609 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0 \ltrch\fcs0
\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0
\f37\fs20\insrsid14885609\charrsid14885609 \trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574\row \ltrrow}\trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trkeep\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrnone
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574\pard \ltrpar\qr \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Weight\cell
}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\*\bkmkstart TkftgNTwzhXhYJSKXbpk}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield
000200001400000014546b6674674e54777a685868594a534b5862706b00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TkftgNTwzhXhYJSKXbpk}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Weight}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0
\b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\bkmkend TkftgNTwzhXhYJSKXbpk}\cell }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609
\hich\af1\dbch\af31505\loch\f1 Date & Result: }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \ab\af0
\ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\datafield 00000000140000000654657874323900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text29}}}}}{\fldrslt {\rtlch\fcs1
\ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang1024\langfe1024\noproof\langfenp1033\insrsid14885609\charrsid14885609 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0 \ltrch\fcs0
\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0
\f37\fs20\insrsid14885609\charrsid14885609 \trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrnone
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574\row \ltrrow}\trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trkeep\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574\pard \ltrpar\qr \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 BMI\cell }\pard \ltrpar
\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1
FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield 000200001400000014544e784b6b38525468376a636a6a47375876497500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname
TNxKk8RTh7jcjjG7XvIu}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 BMI}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \cell }{\rtlch\fcs1 \ab\af0
\ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Date & Result: }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \ab\af0 \ltrch\fcs0
\b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\datafield
00000000140000000654657874323900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text29}}}}}{\fldrslt {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang1024\langfe1024\noproof\langfenp1033\insrsid14885609\charrsid14885609
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \f37\fs20\insrsid14885609\charrsid14885609 \trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trkeep\trbrdrt\brdrs\brdrw10
\trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574\row \ltrrow}\trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trrh231\trleft-108\trkeep
\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574\pard \ltrpar\qr \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 BP\cell }\pard \ltrpar
\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\*\bkmkstart TFAqIVj7nIRjytgdc8H2}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield
0002000014000000145446417149566a376e49526a797467646338483200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TFAqIVj7nIRjytgdc8H2}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Blood Pressure}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0
\b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\bkmkend TFAqIVj7nIRjytgdc8H2}\cell }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609
\hich\af1\dbch\af31505\loch\f1 Date & Result: }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \ab\af0
\ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\datafield 00000000140000000654657874323900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text29}}}}}{\fldrslt {\rtlch\fcs1
\ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang1024\langfe1024\noproof\langfenp1033\insrsid14885609\charrsid14885609 \loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20
\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0 \ltrch\fcs0
\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0
\f37\fs20\insrsid14885609\charrsid14885609 \trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trrh231\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trrh323\trleft-108\trkeep
\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth996\clshdrawnil\clhidemark \cellx7797\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth1300\clshdrawnil\clhidemark \cellx10574\pard \ltrpar\qr \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \af0 \ltrch\fcs0
\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Smoking\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield
000200001400000014544456735a4f746b447363484e4949473854576d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TDVsZOtkDscHNIIG8TWm}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Smoking}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0\afs20 \ltrch\fcs0
\b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \cell }\pard \ltrpar\qr \li0\ri0\sl320\slmult0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \af1 \ltrch\fcs0
\f1\fs20\cf1\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Never smoked}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs20\cf1\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Past smoker
\par }\pard \ltrpar\qr \li0\ri0\sl320\slmult0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs20\cf1\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Current smoker}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \cell }\pard \ltrpar\ql \li0\ri0\sl320\slmult0\keepn\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield
650000001400000007436865636b313300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check13}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609
\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield
650000001400000007436865636b313300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check13}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609
\par }\pard \ltrpar\ql \li0\ri0\sl320\slmult0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609
\hich\af1\dbch\af31505\loch\f1 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield 650000001400000007436865636b313300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check13}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0
\f37\fs20\insrsid14885609\charrsid14885609 \trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trrh323\trleft-108\trkeep\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669
\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth996\clshdrawnil\clhidemark \cellx7797\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
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\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth680\clshdrawnil\clhidemark \cellx1345\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2024\clshdrawnil \cellx5669\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth2\clwWidth2296\clshdrawnil\clhidemark \cellx10574
\pard \ltrpar\qr \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609
\hich\af1\dbch\af31505\loch\f1 Alcohol consumption\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14885609 {\*\bkmkstart Tmkb89A7Jd4o6kYTZfEL}{\field\fldedit{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14885609\charrsid14885609 {\*\datafield
000200001400000014546d6b62383941374a64346f366b59545a66454c00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Tmkb89A7Jd4o6kYTZfEL}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 Alcohol Consumption}}}\sectd \ltrsect\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0\afs20
\ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\bkmkend Tmkb89A7Jd4o6kYTZfEL}\cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \ab\af0 \ltrch\fcs0
\b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 FORMTEXT }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 {\*\datafield
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\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20\loch\af1\dbch\af31505\hich\f1 \u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery539\footery386\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid15213354\sftnbj {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \b\f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 }{
\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \f1\fs20\cf1\lang2057\langfe1033\langfenp1033\insrsid14885609\charrsid14885609 \hich\af1\dbch\af31505\loch\f1 units per week\cell }\pard \ltrpar
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\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14885609\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
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\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5046627 {\*\bkmkend Tx8xXBBytpaLVJkoKZa2}
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\par
\par {\*\bkmkstart TDVsZOtkDscHNIIG8TWm}
\par {\*\bkmkstart TNxKk8RTh7jcjjG7XvIu}
\par {\*\bkmkend TNxKk8RTh7jcjjG7XvIu}
\par {\*\bkmkend TDVsZOtkDscHNIIG8TWm}
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16136900 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid6510927\charrsid16136900
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