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Background Questionnaire

Confidential: For Report Purposes Only

Thank you for filling out the following questionnaire.  Please click "Submit" at the end of each section. (Note: You will not be able to save your progress, so please complete each section fully before submitting.)

Know that this information is very important to the assessment, so please be comprehensive and provide as much detail as possible.

* Indicates a required field.

    Section 7: Medical History



    If applicable, please include NAME of specialist, DATE of evaluation, and DIAGNOSIS given. If not applicable, write N/A.
    If applicable, please include NAME of specialist, DATE of evaluation, and DIAGNOSIS given. If not applicable, write N/A.
    If applicable, please include NAME of specialist, DATE of evaluation, and DIAGNOSIS given. If not applicable, write N/A.
    If applicable, please include NAME of specialist, DATE of evaluation, and DIAGNOSIS given. If not applicable, write N/A.
    If applicable, please include NAME of specialist, DATE of evaluation, and DIAGNOSIS given. If not applicable, write N/A.
    If applicable, please include NAME of specialist, DATE of evaluation, and DIAGNOSIS given. If not applicable, write N/A.



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Copyright Janiece Turnbull PhD. All rights reserved.
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