ࡱ> %` *bjbj"x"x 4@@@!1 ...8fD  :($&h =.e5& 0:(T((UX:   $.   .    Patient Questionnaire ITxM Diagnostics Hemostasis & Thrombosis Clinic Franklin A. Bontempo, M.D. Irina Chibisov, M.D. Patient Name:______________________________________________________ Address:___________________________________________________________ City:___________________________________State:________Zip:___________ Phone:_______________ Work:______________ Cell:_____________________ Email address: _____________________________________________________ Emergency Contact:____________________________Relationship:_________ Address:__________________________________________________________ City:________________________________State:__________Zip:___________ Phone:_______________Work:________________Cell:____________________ Referred By:________________________Phone:__________Fax:___________ Address:___________________________________________________________ City:________________________________State:__________Zip:____________ PCP:_____________________________Phone:____________Fax:___________ Address:__________________________________________________________ City:__________________________________State:________Zip:___________ Pharmacy:_________________________Phone:___________Fax:___________ Address:___________________________________________________________ City:_________________________________State:_________Zip:____________ Appointment Date:________________________ Time:__________________ Doctor:______ FAMILY HISTORY: MOTHER ALIVE Yes____ Age____ FATHER ALIVE Yes____ Age____ If NO, Age at the time of death_________ If NO, Age at the time of death_______ Cause of death_______________________ Cause of death_____________________ BROTHERS & SISTERS: AGE SEX MEDICAL PROBLEMS ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ CHILDREN: AGE SEX MEDICAL PROBLEMS ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ ____ ____ __________________________________________________________ SOCIAL HISTORY: Marital Status Single_____ Married_____ Separated_____ Divorced_____ Widowed_____ With whom do you live? _____________________________________________________________ Are you a student? ______ If yes, Where?______________________________________________ Are you employed? ______ If yes, Where? ______________________________________________ Job Title:__________________________________________________ Are you physically active? ________ If yes, How? ________________________________________ Are you under stress? ________ Work______________ Home______________ Other________ PRESCRIPTION MEDICATIONS: NAME:DOSE:HOW OFTEN: OVER THE COUNTER MEDICATIONS REGULARLY TAKEN: (EXAMPLE: ASPIRIN) NAME:DOSE:HOW OFTEN: ALLERGIES: TYPE OF ALLERGY:TYPE OF REACTION: DRUG, ALCOHOL & TOBACCO HISTORY: SUBSTANCE:AMT PER DAY/WEEK:STARTED:LAST USED:TOBACCOALCOHOLRECREATIONAL DRUGSIV DRUGS HOSPITALIZATIONS AND SURGERIES: DATE:REASON FOR ADMISSION:VASCULAR COMPLICATIONS: EXISTING MEDICAL CONDITIONS: NAME:HOW LONG YOU HAVE HAD THE CONDITION: PAST MEDICAL CONDITIONS: NAME:HOW LONG DID YOU HAVE THIS CONDITION: FAMILY HISTORY: PATIENTMOTHERFATHERBROTHERSISTERCHILDGRANDPARENTANEMIA BLOOD PROBLEMSCLOTS LEGS/LUNGSDIABETESHIGH BLOOD PRESSUREHEART ATTACKSTROKEKIDNEY DISEASELEUKEMIACANCER: SITEOTHEROTHER REVIEW OF SYMPTOMS CATEGORYSYMPTOMYESNOHOW LONGGENERALWEIGHT LOSSNIGHT SWEATSFEVERFATIGUESKINRASHESLUMPSITCHINGDRYNESSBLEEDING MOLESCHANGE IN NAILSSKIN LESIONSSKIN ULCERATIONSINCREASED BRUISINGMUSCULOSKELETALBONE PAINJOINT PAINARTHRITISGOUTBACK PAINMUSCLE PAINCLOTS IN LEGSVARICOSE VEINSLEG SWELLINGLEG PAINEXTREMITY NUMBNESSBLOOD IN JOINTSBLOOD IN MUSCLESNEUROLOGICALSEIZURESPARALYSISLOCAL WEAKNESSNUMBNESSTINGLINGTREMORSMEMORY LOSSFAINTING SPELLSDIZZINESS CATEGORYSYMPTOMYESNOHOW LONGHEADHEADACHESHEAD INJURYVISION CHANGESDOUBLE VISIONEAR INFECTIONDIZZINESSSINUS PROBLEMSNOSE BLEEDSBLEEDING GUMSGINGIVITISSORE THROATHOARSENESSNECKLUMPS IN NECKSWOLLEN GLANDSGOITERTHYROIDLUNGSCOUGHCOUGH W/BLOODCLOTS IN LUNGSASTHMASHORTNESS OF BREATHBREASTLUMPSDISCHARGEPAINCARDIACHIGH BLOOD PRESSUREHEART MURMURLEG OR HAND SWELLINGCHEST PAINPALPITATIONSRHEUMATIC FEVERHEART PROBLEMSPACE MAKERVALVE PROBLEMS CATEGORYSYMPTOMSYESNOHOW LONGURINARYINCREASED FREQUENCYNIGHT URINATIONPAIN WITH URINATIONBLOOD IN URINEURGENCYHESITANCYLOSS OF CONTROLINFECTIONSTONESGASTROINTESTINALHEART BURNLOSS OF APPETITENAUSEAVOMITINGVOMITING BLOODINDIGESTIONABDOMINAL PAINABDOMINAL FULLNESSDIARRHEACONSTIPATIONBLOODY STOOLSHEMORROIDSBLACK TARRY STOOLSJAUNDICELIVER PROBLEMSGALLBLADDERESOPHAGEAL VARICESHEMATOLOGYANEMIAHIGH RBCPLATELET COUNT HIGHPLATELET COUNT LOWABNORMAL BRUISINGGENETIC TESTINGMISC.HOT INTOLERANCECOLD INTOLERANCEHANDS TURN WHITE IN THE COLD DO YOU EAT SALADS? YES __________ NO _____________ DO YOU DRINK OR EAT ANY CITRUS? YES __________ NO ______________ LAST LAB WORK? __________________________________ HAVE YOU EVER HAD OR DO YOU HAVE:YESNOPin point red spots on the skinSmall or large bruisingProlonged bleeding with cutsNose bleeds as a child or adultBleeding gumsBleeding after dental procedure, wisdom teeth or dental extractionDark tarry stool/bloody stoolTIA/Stroke/Heart AttackPhlebitisMigraines FEMALES ONLY: Premenstrual Migraines: Yes __________ No _______________ Menstrual Cycles: Regular ______ Irregular _________ Mentrual Flow: Light ________ Heavy ____________ Birth Control: Yes__________ How Long_______________ No__________ Number of Pregnancies: ________________________________________________________ Number of Deliveries: Live___________ Premature_________ Ectopic_____________ Number of Abortions: Spontaneous _______Elective____________ What Trimester______ Placenta Previa: Yes___________ No________________ Pre-Eclampsia: Yes___________ No________________ Hormone Therapy: Yes___________ Type________________ No_______________     Page  PAGE 9 of  NUMPAGES 9 1>EFGaj     / 5 Z [ \ _ c z 罱}ung}u`ngunun hL ht3Z hL hx| hL h7hL hv 5hL ht3Z5hL hx|5hL h]H 5hL h75hL hR9J5hL h9 a5mHsHhL hR9J5mHsHhL h75mHsHh75CJaJhR9J5CJaJhx|h_B5CJaJhx|h o5CJaJhx|h75CJaJ%'FG  Y Z , - r s B C D gd]H gd7gdR9J$a$gd7$a$gd]H )*  + , - [ h s B C D e f h      ( + 8 ? B Y \ k p ︰︰hL ht3Z5 hL hihL hx|5hL hi5 hL h]H hL h]H 5hL hL hv hL h7 hL ht3Z hL hx|hL hv 5hL h75?    Z [ ) * n o      gd7    A F j k m o |      6?OSmpt79;Peg h&5 h5h7h&5 h+5 hD95 hv 5 hR9J5 h<5 h=5hL hy65 hL hL hi hL ht3ZhL ht3Z5hL hi5hL hv 5 hL hv hL hi8 ;<PQY'; p>?@PQgd7]^#$~  $Ifgd7gd7 kkd$$IflF d'h h h t06    44 la $Ifgd7tkkk $Ifgd7kdT$$IflF d'h h h t06    44 la !"#tkkk $Ifgd7kd$$IflF d'h h h t06    44 la#$%&'tkkk $Ifgd7kd$$IflF d'h h h t06    44 la'()*+tkkk $Ifgd7kdP$$IflF d'h h h t06    44 la+,-./tkkk $Ifgd7kd$$IflF d'h h h t06    44 la/0123tkkk $Ifgd7kd$$IflF d'h h h t06    44 la34567tkkk $Ifgd7kdL$$IflF d'h h h t06    44 la789:;tkkk $Ifgd7kd$$IflF d'h h h t06    44 la;<=>?tkkk $Ifgd7kd$$IflF d'h h h t06    44 la?@ABCtkkk $Ifgd7kdH$$IflF d'h h h t06    44 laCDEFGtkkk $Ifgd7kd$$IflF d'h h h t06    44 laGHIJKtkkk $Ifgd7kd$$IflF d'h h h t06    44 laKLMNOtkkk $Ifgd7kdD$$IflF d'h h h t06    44 laOPQRStkkk $Ifgd7kd$$IflF d'h h h t06    44 laSTUVWtkkk $Ifgd7kd$$IflF d'h h h t06    44 laWXYZ[tkkk $Ifgd7kd@$$IflF d'h h h t06    44 la[\]^_tkkk $Ifgd7kd$$IflF d'h h h t06    44 la_`abctkkk $Ifgd7kd$$IflF d'h h h t06    44 lacdefgtooooofff $Ifgd7gd7kd<$$IflF d'h h h t06    44 la tkkk $Ifgd7kd$$IflF d'h h h t06    44 latkkk $Ifgd7kd$$IflF d'h h h t06    44 latkkk $Ifgd7kd8$$IflF d'h h h t06    44 latkkk $Ifgd7kd$$IflF d'h h h t06    44 latkkk $Ifgd7kd$$IflF d'h h h t06    44 latkkk $Ifgd7kd4$$IflF d'h h h t06    44 latkkk $Ifgd7kd$$IflF d'h h h t06    44 latkkk $Ifgd7kd$$IflF d'h h h t06    44 latkkk $Ifgd7kd0 $$IflF d'h h h t06    44 latkkk $Ifgd7kd $$IflF d'h h h t06    44 latkkk $Ifgd7kd $$IflF d'h h h t06    44 latkkk $Ifgd7kd, $$IflF d'h h h t06    44 latkkk $Ifgd7kd $$IflF d'h h h t06    44 latkkk $Ifgd7kd $$IflF d'h h h t06    44 latkkk $Ifgd7kd( $$IflF d'h h h t06    44 la!3rmmmmmmmmdd $Ifgd7gd7kd| $$Ifl1F d'h h h t06    44 la _`RScelmstz{شثشhB5CJaJhhB5CJaJhh5CJaJhBhB5CJaJh5CJaJ hB5 h5 hb_5 hR9J5 hW5 hx5C3456~~ $Ifgd7xkd $$Ifl0' t0644 la6789~~ $Ifgd7xkd $$Ifl0' t0644 la9:;<~~ $Ifgd7xkdl $$Ifl0' t0644 la<=>?~~ $Ifgd7xkd $$Ifl0' t0644 la?@AB~~ $Ifgd7xkd $$Ifl0' t0644 laBCDE~~ $Ifgd7xkdP $$Ifl0' t0644 laEFGH~~ $Ifgd7xkd $$Ifl0' t0644 laHIJK~~ $Ifgd7xkd $$Ifl0' t0644 laKLMN~~ $Ifgd7xkd4$$Ifl0' t0644 laNOPQ~~ $Ifgd7xkd$$Ifl0' t0644 laQRST~~ $Ifgd7xkd$$Ifl0' t0644 laTUVW~~ $Ifgd7xkd$$Ifl0' t0644 laWXYZ~~ $Ifgd7xkdd$$Ifl0' t0644 laZ[\]~~ $Ifgd7xkd$$Ifl0' t0644 la]^_`yyyy $Ifgd7gd7xkd$$Ifl0' t0644 la ^UUUU $Ifgd7kdH$$Ifl\ X '`  pt t0644 la^UUUU $Ifgd7kd$$Ifl\ X '`  pt t0644 la^UUUU $Ifgd7kd^$$Ifl\ X '`  pt t0644 la^UUUU $Ifgd7kd$$Ifl\ X '`  pt t0644 la/G^YYYYPPP $Ifgd7gd7kdt$$Ifl\ X '`  pt t0644 laGHIJKqhhh $Ifgd7kd$$IflF4't, t06    44 laKLMNOqhhh $Ifgd7kdt$$IflF4't, t06    44 laOPQRSqhhh $Ifgd7kd$$IflF4't, t06    44 laSTUVWqhhh $Ifgd7kd^$$IflF4't, t06    44 laWXYZ[qhhh $Ifgd7kd$$IflF4't, t06    44 la[\]^_qhhh $Ifgd7kdH$$IflF4't, t06    44 la_`abcqhhh $Ifgd7kd$$IflF4't, t06    44 lacdefgqhhh $Ifgd7kd2$$IflF4't, t06    44 laghijkqhhh $Ifgd7kd$$IflF4't, t06    44 laklmnoqhhh $Ifgd7kd$$IflF4't, t06    44 laopqrsqhhh $Ifgd7kd$$IflF4't, t06    44 lastuvwqhhh $Ifgd7kd$$IflF4't, t06    44 lawxyz{qhhh $Ifgd7kd{$$IflF4't, t06    44 la{|}~qhhh $Ifgd7kd$$IflF4't, t06    44 laqlllllllllc $Ifgd7gd7kde$$IflF4't, t06    44 la {zkd$$Ifl0'| t0644 la $Ifgd7{{ $Ifgd7zkd9$$Ifl0'| t0644 la{{ $Ifgd7zkd$$Ifl0'| t0644 la{{ $Ifgd7zkd$$Ifl0'| t0644 la{{ $Ifgd7zkdV$$Ifl0'| t0644 la{{ $Ifgd7zkd$$Ifl0'| t0644 la{{ $Ifgd7zkd$$Ifl0'| t0644 la{{ $Ifgd7zkds$$Ifl0'| t0644 la{{ $Ifgd7zkd$$Ifl0'| t0644 la 5vv $Ifgd7gd7zkd1$$Ifl0'| t0644 la5678{{ $Ifgd7zkd$$Ifl0'| t0644 la89:;{{ $Ifgd7zkd$$Ifl0'| t0644 la;<=>{{ $Ifgd7zkdN$$Ifl0'| t0644 la>?@A{{ $Ifgd7zkd$$Ifl0'| t0644 laABCD{{ $Ifgd7zkd $$Ifl0'| t0644 laDEFG{{ $Ifgd7zkdk$$Ifl0'| t0644 laGHIJ{{ $Ifgd7zkd$$Ifl0'| t0644 laJKLM{{ $Ifgd7zkd) $$Ifl0'| t0644 laMNOP{{ $Ifgd7zkd $$Ifl0'| t0644 laPQRScdemt{vvvvvvvv $Ifgd7gd7zkd $$Ifl0'| t0644 la kdF!$$Iflִ xd"&( t0(6    44 la $Ifgd7 $Ifgdkd-"$$Iflִ xd"&( t0(6    44 la $Ifgd7kd#$$Iflmִ xd"&( t0(6    44 la $Ifgd7 kd#$$Ifl|ִ xd"&( t0(6    44 la $Ifgd7   &'./56=>EFNOVW^_cdklqryzbuz h|;5hl,hXX5CJaJhl,hXX5CJaJ hXX5 hR9J5hB5CJaJhh5CJaJhhB5CJaJh5CJaJ h5 hB5@kd$$$Iflִ xd"&( t0(6    44 la  $Ifgd7  kd%$$Iflmִ xd"&( t0(6    44 la  $Ifgd7 $Ifgd  kd&$$Iflmִ xd"&( t0(6    44 la '()*+,-. $Ifgd7./kd'$$Iflִ xd"&( t0(6    44 la/6>?@ABCDE $Ifgd7 EFkd~($$Iflmִ xd"&( t0(6    44 laFOPQRSTUV $Ifgd7VWkde)$$Iflִ xd"&( t0(6    44 laW_defghijk $Ifgd7 klkdL*$$Ifl|ִ xd"&( t0(6    44 lalrstuvwxy $Ifgd7yzkd3+$$Iflִ xd"&( t0(6    44 laz $Ifgd7kd,$$IflFִ xd"&( t0(6    44 la $$Ifa$gdXX$a$gdXXgd7 K????? $$Ifa$gdXXkd-$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd-$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkdC.$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd.$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd/$$IflrE h ' ]  t0644 la K????? $$Ifa$gdXXkd&0$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd0$$IflrE h ' ]  t0644 la &'()K????? $$Ifa$gdXXkdh1$$IflrE h ' ]  t0644 la)*+3456K????? $$Ifa$gdXXkd 2$$IflrE h ' ]  t0644 la678@ABCK????? $$Ifa$gdXXkd2$$IflrE h ' ]  t0644 laCDETUVWK????? $$Ifa$gdXXkdK3$$IflrE h ' ]  t0644 laWXYijklK????? $$Ifa$gdXXkd3$$IflrE h ' ]  t0644 lalmn{|}~K????? $$Ifa$gdXXkd4$$IflrE h ' ]  t0644 la~K????? $$Ifa$gdXXkd.5$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd5$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkdp6$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd7$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd7$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkdS8$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd8$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd9$$IflrE h ' ]  t0644 la  K????? $$Ifa$gdXXkd6:$$IflrE h ' ]  t0644 la)*+,K????? $$Ifa$gdXXkd:$$IflrE h ' ]  t0644 la,-.=>?@K????? $$Ifa$gdXXkdx;$$IflrE h ' ]  t0644 la@ABOPQRK????? $$Ifa$gdXXkd<$$IflrE h ' ]  t0644 laRST]^_`K????? $$Ifa$gdXXkd<$$IflrE h ' ]  t0644 la`abuvwxK????? $$Ifa$gdXXkd[=$$IflrE h ' ]  t0644 laxyzK????? $$Ifa$gdXXkd=$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd>$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd>?$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd?$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd@$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkd!A$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkdA$$IflrE h ' ]  t0644 laK????? $$Ifa$gdXXkdcB$$IflrE h ' ]  t0644 la  K????? $$Ifa$gdXXkdC$$IflrE h ' ]  t0644 la "17@EFHLO  ! % * 1 8 K L Q ] c w x } *!>!X!l!x""""""""""լսէէէէ՛hnhn5CJaJ hn5 hL 5h/h|;5CJaJh/h/5CJaJh/h/5CJaJ h/5h/h|;5CJaJ hR9J5 hl,5 h5 hXX5 h|;5: K????? $$Ifa$gdXXkdC$$IflrE h ' ]  t0644 la !"2345K????? $$Ifa$gdXXkdFD$$IflrE h ' ]  t0644 la567ABCDK????? $$Ifa$gdXXkdD$$IflrE h ' ]  t0644 laDEFGHIJKKCCCCCC$a$gdXXkdE$$IflrE h ' ]  t0644 laKLMNOX`dgp $$Ifa$gdXX$a$gdXX pqvwxyzK????? $$Ifa$gdXXkd)F$$Iflr P<'  8 t0644 laz{|K????? $$Ifa$gdXXkdF$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdkG$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkd H$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdH$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdNI$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdI$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdJ$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkd1K$$Iflr P<'  8 t0644 la  K????? $$Ifa$gdXXkdK$$Iflr P<'  8 t0644 la()*+K????? $$Ifa$gdXXkdsL$$Iflr P<'  8 t0644 la+,-9:;<K????? $$Ifa$gdXXkdM$$Iflr P<'  8 t0644 la<=>IJKLK????? $$Ifa$gdXXkdM$$Iflr P<'  8 t0644 laLMRSTUVK????? $$Ifa$gdXXkdVN$$Iflr P<'  8 t0644 laVWXfghiK????? $$Ifa$gdXXkdN$$Iflr P<'  8 t0644 laijkz{|}K????? $$Ifa$gdXXkdO$$Iflr P<'  8 t0644 la}~K????? $$Ifa$gdXXkd9P$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdP$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkd{Q$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdR$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdR$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkd^S$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdS$$Iflr P<'  8 t0644 laK????? $$Ifa$gdXXkdT$$Iflr P<'  8 t0644 la     K????? $$Ifa$gdXXkdAU$$Iflr P<'  8 t0644 la      K????? $$Ifa$gdXXkdU$$Iflr P<'  8 t0644 la       K????? $$Ifa$gdXXkdV$$Iflr P<'  8 t0644 la ! & ' ( ) K????? $$Ifa$gdXXkd$W$$Iflr P<'  8 t0644 la) * 2 3 4 5 6 K????? $$Ifa$gdXXkdW$$Iflr P<'  8 t0644 la6 7 8 L M N O K????? $$Ifa$gdXXkdfX$$Iflr P<'  8 t0644 laO P Q ^ _ ` a K????? $$Ifa$gdXXkdY$$Iflr P<'  8 t0644 laa b c x y z { K????? $$Ifa$gdXXkdY$$Iflr P<'  8 t0644 la{ | } K????? $$Ifa$gdXXkdIZ$$Iflr P<'  8 t0644 la K????? $$Ifa$gdXXkdZ$$Iflr P<'  8 t0644 la K????? $$Ifa$gdXXkd[$$Iflr P<'  8 t0644 la K????? $$Ifa$gdXXkd,\$$Iflr P<'  8 t0644 la K????? $$Ifa$gdXXkd\$$Iflr P<'  8 t0644 la K????? $$Ifa$gdXXkdn]$$Iflr P<'  8 t0644 la K????? $$Ifa$gdXXkd^$$Iflr P<'  8 t0644 la KCCCCCC$a$gdXXkd^$$Iflr P<'  8 t0644 la ! !!!! $$Ifa$gdXX$a$gdXX!!$!%!&!'!(!K????? $$Ifa$gdXXkdQ_$$Iflr P<'  8 t0644 la(!)!*!>!?!@!A!K????? $$Ifa$gdXXkd_$$Iflr P<'  8 t0644 laA!B!C!S!T!U!V!K????? $$Ifa$gdXXkd`$$Iflr P<'  8 t0644 laV!W!X!l!m!n!o!K????? $$Ifa$gdXXkd4a$$Iflr P<'  8 t0644 lao!p!q!!!!!K????? $$Ifa$gdXXkda$$Iflr P<'  8 t0644 la!!!!!!!K????? $$Ifa$gdXXkdvb$$Iflr P<'  8 t0644 la!!!!!!!K????? $$Ifa$gdXXkdc$$Iflr P<'  8 t0644 la!!!!!!!K????? $$Ifa$gdXXkdc$$Iflr P<'  8 t0644 la!!!!!!!K????? $$Ifa$gdXXkdYd$$Iflr P<'  8 t0644 la!!!!!!!K????? $$Ifa$gdXXkdd$$Iflr P<'  8 t0644 la!!!!!!!K????? $$Ifa$gdXXkde$$Iflr P<'  8 t0644 la!!!!!!!K????? $$Ifa$gdXXkd%V%W%X%nbbb $$Ifa$gdXXkdx$$IflFl!'T  t06    44 layt9KrX%Y%v%w%x%nbbb $$Ifa$gdXXkdoy$$IflFl!'T  t06    44 layt9Krx%y%%%%nbbb $$Ifa$gdXXkdy$$IflFl!'T  t06    44 layt9Kr%%%%%nbbb $$Ifa$gdXXkdez$$IflFl!'T  t06    44 layt9Kr%%%%%nbbb $$Ifa$gdXXkdz$$IflFl!'T  t06    44 layt9Kr%%&&&nbbb $$Ifa$gdXXkd[{$$IflFl!'T  t06    44 layt9Kr&&,&-&.&nbbb $$Ifa$gdXXkd{$$IflFl!'T  t06    44 layt9Kr.&/&9&:&;&nbbb $$Ifa$gdXXkdQ|$$IflFl!'T  t06    44 layt9Kr;&<&F&G&H&nbbb $$Ifa$gdXXkd|$$IflFl!'T  t06    44 layt9KrH&I&J&K&L&nbbb $$Ifa$gdXXkdG}$$IflFl!'T  t06    44 layt9KrL&M&N&O&P&Q&R&S&T&U&V&d&nffffffffff$a$gdXXkd}$$IflFl!'T  t06    44 layt9Kr d&e&&'Q''(q(( )q)))))))))))****$a$gdXX&''''((())))))))))))))))))))*****hL 0JmHnHu hL 0JjhL 0JUhL hXjhXU h1Po5 h.+5 21h:pR9J/ =!"# $% R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h R$$If!vh5h 5h 5h #vh :Vl t65h V$$If!vh5h 5h 5h #vh :Vl1 t65h J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65$$If!vh5` 5 5p5t#v` #v #vp#vt:Vl t65` 5 5p5t$$If!vh5` 5 5p5t#v` #v #vp#vt:Vl t65` 5 5p5t$$If!vh5` 5 5p5t#v` #v #vp#vt:Vl t65` 5 5p5t$$If!vh5` 5 5p5t#v` #v #vp#vt:Vl t65` 5 5p5t$$If!vh5` 5 5p5t#v` #v #vp#vt:Vl t65` 5 5p5ts$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5s$$If!vh5t5,5#vt#v,#v:Vl t65t5,5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5]$$If!vh5|5#v|#v:Vl t65|5$$If!vh55555555#v#v#v#v#v#v#v#v:Vl t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vl t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vlm t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vl| t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vl t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vlm t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vlm t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vl t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vlm t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vl t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vl| t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:Vl t(655555555$$If!vh55555555#v#v#v#v#v#v#v#v:VlF t(655555555$$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5b55 #v #v #vb#v#v :Vl t65 5] 555 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 $$If!vh5 5 5855 #v #v #v8#v#v :Vl t65 5 5855 y$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kry$$If!vh55T5 #v#vT#v :Vl t655T5 yt9Kr@@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k(No ListHH x| Balloon TextCJOJQJ^JaJj@j < Table Grid7:V04@4 L Header  !4 @"4 L Footer  !.)@1. L Page Number" @'FGYZ,-rsBCDZ[)*no      ;<PQY'  ; p > ? @ P Q   ] ^ #$~  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefg!3456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`/GHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~ 56789:;<=>?@ABCDEFGHIJKLMNOPQRScdemt{   '()*+,-./6>?@ABCDEFOPQRSTUVW_defghijklrstuvwxyz  &'()*+345678@ABCDETUVWXYijklmn{|}~  )*+,-.=>?@ABOPQRST]^_`abuvwxyz   !"234567ABCDEFGHIJKLMNOX`dgpqvwxyz{|  ()*+,-9:;<=>IJKLMRSTUVWXfghijkz{|}~  !&'()*2345678LMNOPQ^_`abcxyz{|} $%&'()*>?@ABCSTUVWXlmnopq     "#$%&'6789:;GHIJKL[\]^_`stuvwx()*+,-.56789:CDEFGH\]^_`atuvwxy`a;<=>VWXYvwxy,-./9:;<FGHIJKLMNOPQRSTUVdeQ q !q!!!!!!!!!!!"""00000000000000000@0000@000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000000000000000X00X00X00X00X00X00X00X00@0X00X00(= 0003 "&*B  #'+/37;?CGKOSW[_c369<?BEHKNQTWZ]GKOSW[_cgkosw{58;>ADGJMP   ./EFVWklyz)6CWl~,@R`x 5DKpz+<LVi}   ) 6 O a { !(!A!V!o!!!!!!!!! ""%"9"J"^"v""""""""##,#8#F#_#w#######$%=%X%x%%%%&.&;&H&L&d&* !"#$%&'()*+,-./0123456789:;<=>?@ACDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~     * +-3!8@0(  B S  ?Ga7gM{\ c $!-!!!!!!!!!!!!!""G^`>@z|OQbd13su'1<F " !!!!!!!!!!!!!!""33333333333333333333333333-   ?gSLO>yQ!!!!!!!!!!!!!!!!""!!!!!!!!!!!!""\[]Qv L ]H 0&XndYmH'.+l,'F0/o3D9Q:3#D$HJR9JkLYPjoPR*S-TXXt3ZFZ\`9 aad:i1PoQ1p9Kreu#vxG{c|RW|}/wL7]p<lyB\]nc_BIEv o=x*|;eo38ewqWy6z=+ c[b_Kx|7yJji&e7  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcd!3456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^/GHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~ 56789:;<=>?@ABCDEFGHIJKLMNOPQdemt{   '()*+,-./>?@ABCDEFOPQRSTUVWdefghijklrstuvwxyz  &'()*+345678@ABCDETUVWXYijklmn{|}~  )*+,-.=>?@ABOPQRST]^_`abuvwxyz   !"234567ABCDEOX`dgpqvwxyz{|  ()*+,-9:;<=>IJKLMRSTUVWXfghijkz{|}~  !&'()*2345678LMNOPQ^_`abcxyz{|} $%&'()*>?@ABCSTUVWXlmnopq     "#$%&'6789:;GHIJKL[\]^_`stuvwx()*+,-.56789:CDEFGH\]^_`atuvwxy;<=>VWXYvwxy,-./9:;<FGHIJKLM"@ؓ "@UnknownG: Times New Roman5Symbol3& : Arial5& zaTahoma"1h&FS3Ҧ8 = =! 4d!!2QHX ?72Patient QuestionaireRichelle Brown-Robinson AdministratorOh+'0 0< \ h t Patient QuestionaireRichelle Brown-Robinson Normal.dotAdministrator16Microsoft Office Word@P+@Z@<3@O ՜.+,0 hp  ITXM=!' Patient Questionaire Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      "#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`bcdefghijklmnopqrstuvwxyz{|}~Root Entry F Data !=~1Tablea(WordDocument4@SummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q