ࡱ> a (bjbjrr ژL\L\], , DhlTVf((LtttPPPZV\V\V\V\V\V\V$AZ\VPD P"PPVtt")VRRRPttZVRPZVRRU|UtP{ JQBUFVV0VU]RF]$U]UPPRPPPPPVVRPPPVPPPP]PPPPPPPPP, > j: Confidential Health History QuestionnaireName: Date:Address (Street, City, State, Zip): Home Phone:Cell Phone:Work Phone:Email:Date of Birth:Age:Gender:Best way to contact you:Is it ok to leave messages? Employment status: Fulltime / Parttime / Student / Other (describe:)Occupation:Employer (Name and City):Emergency Contact:Phone:Relationship to you:Status: Single/ Married/ Living with Partner/ Divorced/ Widowed/ SeparatedChildren: Yes / No Ages: How did you hear about us?Have you had acupuncture before? Yes/ NoPrimary Care Physician:Street Address:City, State, Zip:Phone:  Main Problems/Reasons for VisitAdditional issues you would like to address1.1.2.2.3.3.4.4. What is the main issue you would like to focus on today?   When did this problem begin? (Please be specific)  What do you think caused it? Is the cause still present?  What treatments have you tried already? What were the results?   Have you been given a diagnosis for this problem? If so, what?  To what extent does this problem interfere with your daily activities? (work, sleep, eating, exercise...)   How severe is your problem right now? (Please mark the scale below)  No problem Moderate Worst Imaginable Whats the most severe level you have endured within the last week? (Please mark the scale below)  No problem Moderate Worst Imaginable What are your treatment goals? ( Temporary relief of symptoms/pain control ( Eliminate root or cause of problem (if possible) ( Lessen/eliminate habits which caused the condition or made it worse ( Maintenance care (periodic balancing/tune-up to keep in good health) Current Medication Dose per day For how long? For What Condition?Herbs, Vitamins and Supplements Dose per day For how long? For What Condition? Past Medical History (please indicate by date(s):  Cancer High Blood Pressure Rheumatic Fever Venereal Disease  Diabetes Heart Disease Seizures Asthma  Hepatitis Stroke Thyroid Disease Pacemaker  HIV Surgeries (type and date):  Significant Trauma (auto accidents, falls, etc., include dates):  Significant Dental Work (type and date):  Allergies (drugs, chemicals, foods, animals):  Family Medical History ( High Blood Pressure ( Alcoholism ( Cancer: ( Allergies: ( Heart Disease ( Seizures ( Arteriosclerosis ( Asthma ( Stroke ( Diabetes Other: On the following page, please check boxes of any symptoms you have had in the past 2-4 weeks. (Check, X, bold, underline, or mark your selections clearly.)  General ( Chills ( Fevers ( Sweat easily ( Night sweats ( Localized weakness ( Bleed or bruise easily ( Peculiar tastes or smells ( Strong thirst (cold / hot) ( Thirst, no desire to drink ( Fatigue ( Sudden energy drop Time of day:__________ ( Edema Where:______________ ( Poor sleeping ( Tremors ( Poor balance ( Cravings ( Change in appetite ( Poor appetite ( Weight change Gain / Loss ___________  Skin and Hair ( Rashes ( Itching ( Change in hair or skin ( Ulcerations ( Eczema ( Hives ( Pimples ( Recent moles ( Loss of hair ( Dandruff Other hair or skin problems   Head, Eyes, Ears Nose, and Throat ( Dizziness ( Migraines ( Headaches When:_____________ Where: ____________ ( Facial pain ( Glasses ( Poor vision ( Night blindness ( Blurry vision ( Color blindness ( Blind field ( Spots in front of eyes ( Eye pain ( Eye strain ( Cataracts ( Eye Dryness ( Excessive tearing ( Discharge from eyes ( Poor hearing ( Ringing in ears ( Earaches ( Discharge from ear ( Nose bleeds ( Sinus congestion ( Nasal drainage ( Grinding teeth ( Teeth problems ( Jaw clicks ( Concussions ( Recurrent sore throats ( Hoarseness ( Sores on lips/tongue Other head / neck problems  Cardiovascular ( High blood pressure ( Low blood pressure ( Chest discomfort/pain ( Heart palpitations ( Cold hands or feet ( Swelling of hands ( Swelling of feet ( Blood clots ( Fainting ( Difficulty in breathing Other heart/blood vessel problems: ______________  Respiratory ( Cough ( Asthma/wheezing ( Difficulty in breathing when lying down ( Phlegm Color?________ ( Coughing blood ( Pneumonia ( Bronchitis Other lung problems:______ ______________________ Gastrointestinal ( Bad breath ( Nausea ( Vomiting ( Heartburn ( Belching ( Indigestion ( Diarrhea ( Constipation ( Chronic laxative use ( Blood in stools ( Black stools ( Abdominal pain/cramps ( Gas ( Rectal pain ( Hemorrhoids Other stomach or intestinal problems:______________ _____________________  Genito-Urinary ( Pain on urination ( Urgency to urinate ( Frequent urination ( Blood in urine ( Decrease in flow ( Dribbling ( Kidney stones ( Impotency ( Change of sexual drive ( Sores on genitals Do you wake to urinate? ( Yes ( No How often? ____________ What color is your urine? _____________________ Other genital or urinary system problems?________ _____________________  Pregnancy and Gynecology # of pregnancies: # of births: # premature births: # of miscarriages: # of abortions: Age at first menses: Length of full cycle: Length of menses: Last menses start date: ( Heavy periods ( Light periods ( Painful periods ( Irregular periods ( Changes in body/psyche prior to menstruation ( Clots ( Vaginal discharge: ( Menopause: Age: Year: ( Postcoital bleeding ( Vaginal sores ( Breast lumps ( Nipple discharge Do you practice birth control? ( Yes ( No What type and for how long? _____________________  Musculoskeletal ( Neck pain ( Shoulder pain ( Back pain ( Elbow pain ( Hand/wrist pain ( Hip pain ( Knee pain ( Foot/ankle pain ( Muscle pain ( Muscle weakness Other pain? ____________ _____________________  Neuropsychological ( Seizures ( Areas of numbness ( Weakness ( Sleep disorder ( Concussion ( Violence potential ( Vertigo ( Lack of coordination ( Bad temper ( Depression ( Easily stressed ( Loss of balance ( Poor memory ( Anxiety ( Substance abuse Have you ever been treated for emotional problems? ( Yes ( No Last Physical Date: ________ Doctor: ________________________ Results: ____________________  Lifestyle/Self-care Please indicate below: Yes No Amount/How often (Please describe) Have you ever smoked cigarettes? ( ( Do you currently smoke cigarettes? ( ( Do you drink alcohol? ( ( Do you use recreational drugs? ( ( Previous drug/alcohol issues? ( ( Do you drink caffeinated beverages? ( ( Do you exercise regularly? ( ( Do you have food cravings? ( ( Are there foods you need to avoid? ( ( What type of stress do you have in your life? (chemical, physical, psychological, etc.):   Have there been any major stressors in the past 6 months? (describe) How would you describe your energy level? How would you describe your sleep? Do you enjoy your job? How often do you work? How do you relax or unwind? How is your home life? How do you tend to become imbalanced when overtired or under stress?  Diet Please give a general description of the food you eat during a typical day.  Morning:  Afternoon:  Evening:  Before bed:  Between meals: Are you now, or have you ever been, on a restricted diet? Please describe the diet and give the start/stop dates:  Health Insurance Information: Plan Name: ________________________ Plan #: _________________________________ Insured Name: _____________________________________________     Page  PAGE 4 of  NUMPAGES 4 Pure Health Natural Medicine 541-419-2507 Acupuncture  Page  PAGE 1 of  NUMPAGES 4 *+   ( ) L M & '   " $ p q w x ~    < = > ? ~  砕hE}CJOJQJ\)jhE}CJOJQJU\mHnHuh*qCJOJQJ\h*qCJOJQJ\^Jh-PCJOJQJ\^JhE}CJOJQJ\^JhE}CJOJQJ\hE}5CJOJQJ^J:*+yii ! H($Ifrkd$$Ifl40**  064 laf4p $ ! H($Ifa$ y ! H($Ifvkd$$Ifl40X 0*  064 laf4    (  ! H($Ifckd'$$Ifl40**064 laf4( ) 0 ? D L vffff ! H($Ifkd$$Ifl4F<0* 06    4 laf4L M f cSS ! H($Ifkd=$$Ifl4\e<0*G  064 laf4 y ! H($Ifvkd$$Ifl400*064 laf4  ! H($Ifckdo$$Ifl40**064 laf4  & vvv ! H($Ifykd$$Ifl400*064 laf4ytO|a& ' w vff ! H($Ifkd}$$Ifl4FH<0*  06    4 laf4 yy ! H($Ifvkd$$Ifl40 0*064 laf4  yy ! H($Ifvkd$$Ifl40e0*064 laf4   " yy ! H($Ifvkd$$Ifl40e0*064 laf4" # $ D p ~nn ! H($If  ! H(vkd$$Ifl40e0*064 laf4p q t w ~~ ! H($Ifqkd4$$Ifl40VD%064 laf4w x { ~ ~~ ! H($Ifqkd$$Ifl40VD%064 laf4~  ~~ ! H($IfqkdJ$$Ifl40VD%064 laf4 ~~ ! H($Ifqkd$$Ifl40VD%064 laf4  < > ~ {{{{{{{{{{{{ !<  ! H(qkd` $$Ifl40VD%064 laf4 ! * / 0 1 2 3 4 y |  ]~+,qt;?klqȹȹȹȹ߭nnnn&jhE}CJOJQJUmHnHuhE}CJOJQJhE}CJ OJQJhE}5CJOJQJ\hE}CJOJQJhE}CJOJQJ^J jhE}CJOJQJ^JhE}CJOJQJ^Jh;CJOJQJ\hE}CJOJQJ\)jhE}CJOJQJU\mHnHu+ / 1 3 y } !])rst  !<$If  ! d@ ! d@dh  !<] !<<[kdg $$Ifl|)|)064 lal  !<$If[kd $$Ifl|)|)064 lal<[kd_ $$Ifl|)|)064 lal  !<$If[kd $$Ifl|)|)064 lal    <[kdW $$Ifl|)|)064 lal  !<$If[kd $$Ifl|)|)064 lal  <[kdO $$Ifl|)|)064 lal  !<$If[kd $$Ifl|)|)064 lal<[kdG$$Ifl|)|)064 lal  !<$If[kd $$Ifl|)|)064 lal<[kd?$$Ifl|)|)064 lal  !<$If[kd$$Ifl|)|)064 lal<4 !<[kd7$$Ifl|)|)064 lal  !<$If[kd$$Ifl|)|)064 lal;kq/1H !h @< !pV<  !pV< !pVx< !pP#BB< !P#BB< !xqr/01HI_`mnxy:<BCDL˾⺫#h;h;CJOJQJ\^JaJh;h5CJOJQJ\^JhE}5CJOJQJ\^JhE} jhE}CJOJQJhE}5CJOJQJ\h CJOJQJhE}CJOJQJ&jhE}CJOJQJUmHnHu2Drrr  ! dr@$ ! dr@<-DM a$ ! dr@< ! d@d<^d ! d@d<^d ! dr@d<`d ! @< !h @< LO,-JKUVkİzmzbhE}>*CJOJQJhE}6>*CJOJQJhE}6CJOJQJhE}CJOJQJ jhE}CJOJQJhE}CJOJQJhE}CJOJQJ&jhE}CJOJQJUmHnHuh;hE}CJOJQJaJh;hE}CJaJ#h;h;CJOJQJ\^JaJh;CJOJQJ\^JaJ&,JUk =? ! dr@< ! dr@]  ! dr@%<=>?MNWXbc|}'(45Frsʢ&jhE}CJOJQJUmHnHuhE}CJOJQJhE}CJOJQJ&jhE}CJOJQJUmHnHuhE}6CJOJQJhE}CJOJQJ jhE}CJOJQJ@?MWb| $ ! dr@-DM a$  ! dr@ ! dr@]$ ! dr@<-DM a$ '4AYr#2G^n  ! dr@ ! dr@]$ ! dr@x-DM a$ #$23GH^_no  34ABYtuv   !/ӿhE}CJOJQJhE}CJOJQJ&jhE}CJOJQJUmHnHuhE}6CJOJQJhE}>*CJOJQJhE}CJOJQJ jhE}CJOJQJC 3AYtv$ ! dr@<-DM a$$ ! dr@<a$ ! dr@]  ! dr@  /;Vo (CZ ! dr@]^`$ ! dr@<-DM a$ ! dr@]  ! dr@/0;<V (Z^op}~+,123ABPhE}>*CJOJQJhE}CJOJQJ&jhE}CJOJQJUmHnHuhE}6CJOJQJhE}CJOJQJ jhE}CJOJQJGZ[\]^o}+2AP ! dr@]  ! dr@$ ! dr@<-DM a$$ ! dr@<a$Pl0=Wl$ ! dr@<-DM a$  ! dr@ ! dr@] 01=>WXl&'(@ABTUbcwx+,@Apqyzޡ)jhE}6CJOJQJUmHnHuhE}CJOJQJhE}CJOJQJ&jhE}CJOJQJUmHnHuhE}6CJOJQJ jhE}CJOJQJhE}CJOJQJ?&(6ATbw+@$ ! dr@x-DM a$$ ! dr@-DM a$  ! dr@ ! dr@]@py)F\^ ! dr@^ !Z dr@]^ ! dr@]  ! dr@ ! dr@^`#$(DF[\]^no{| 7 8 9 L M X Y m n y z !!鿵ӿhE}CJOJQJhE}CJOJQJ&jhE}CJOJQJUmHnHuhE}6CJOJQJhE}>*CJOJQJhE}CJOJQJ jhE}CJOJQJC^n{ ! 7 9 L X m y $ ! dr@<-DM ]a$  ! dr@ ! dr@]$ ! dr@<-DM a$ !!#!.!A!\!t!!!!!!"R" !2 j x< ! dr@x  ! dr@ ! dr@]!!!#!$!.!/!A!t!u!v!!!!!!!!!"""R"S"u"v"w"x"y"z"""""""""""""""""""##### #-#.#/#0#3#4#ԵʪԖԖԖԖԖԖ&jhE}CJOJQJUmHnHuhE}5CJOJQJ)jhE}5CJOJQJUmHnHuhE}CJ OJQJhE}CJOJQJhE}6CJOJQJ jhE}CJOJQJhE}CJOJQJ;R"y""""#3#V#z###$$J$v$$%=%V%%% !2 \ < ! @< ! @x< !@ <4#P#Q#R#S#V#W#t#u#v#w#z#{########$$$$$J$K$v$w$$$%%=%>%V%W%%%%%%%%%&& &&&&'&(&&&&"jhE}OJQJUmHnHuhE}OJQJhE}5OJQJhE}CJ OJQJ&jhE}CJOJQJUmHnHu&jhE}CJOJQJUmHnHu jhE}CJOJQJhE}CJOJQJ7%%& &&'&8&&&&&&&&!']'_'`'b'c'e'f'h'  !] !  !x  !x !p@ <&&&]'^'`'a'c'd'f'g'i'j'k'l'm'n'o'u'v'|'}'~'''''''''''''''ɹɹɹɹ؉zn] hmhmCJ OJQJ^JaJ h9CJOJQJ^Jh",h9CJOJQJ^J h",h9CJ OJQJ^JaJ h9h9CJOJQJ hiCJOJQJhmHnHujh9CJOJQJUhh9CJOJQJhhCquhmhczjhczUhh5CJOJQJhCJOJQJ$h'i'j'k'l'm'n'o''''''' ( ( ((  !] !n($dN] $ !(a$ !(  !0*gdm !'$dN'''''''''''''''(( ( ( ( ( ((yhCJOJQJhcz hiCJOJQJhmHnHujh9CJOJQJUhh9CJOJQJhh9CJOJQJh9h9CJOJQJ^J*jh9CJOJQJU^JmHnHuh",h9OJQJ^JaJhLCJ OJQJ^JaJ 2 0 0&P/ =!"#$% 2 0 0&P/ =!8"8#$% 9 0 00&P/ =!8"8#$% P h5 0 00&P/ =!8"8#$% h$$If!vh#v*:V l4  065*4f4p $$If!vh#v #v :V l4065 5 4f4{$$If!vh#v*:V l4065*4f4$$If!vh#v#v#v :V l406555 4f4$$If!vh#v#vG #v#v :V l40655G 55 4f4$$If!vh#v#v:V l406554f4{$$If!vh#v*:V l4065*4f4$$If!vh#v#v:V l406554f4ytO|a$$If!vh#v#v :V l40655 4f4$$If!vh#v#v:V l406554f4$$If!vh#v#v:V l406554f4$$If!vh#v#v:V l406554f4$$If!vh#v#v:V l406554f4$$If!vh#v#v:V l406554f4$$If!vh#v#v:V l406554f4$$If!vh#v#v:V l406554f4$$If!vh#v#v:V l406554f4$$If!vh#v#v:V l406554f4z$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4alz$$Ifl!vh#v|):V l065|)4als06866666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p(8HX`~8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH <`< NormalCJ_HmH sH tH @@  Heading 1$@& CJ OJQJDA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4@4 0Header  !4 @4 Footer  !HH |Z Balloon TextCJOJQJ^JaJN/!N |ZBalloon Text CharCJOJQJ^JaJll mp Grid Table 3$d@& '5B*CJOJPJQJ\^JaJph6_:: mTOC 1x5OJ QJ aJBB mTOC 2 ^5CJOJ QJ aJ>> mTOC 3 ^CJOJ QJ aJ:: mTOC 4 ^ CJOJ QJ :: mTOC 5 ^ CJOJ QJ :: mTOC 6 ^ CJOJ QJ :: mTOC 7 ^ CJOJ QJ :: mTOC 8 ^ CJOJ QJ :: mTOC 9 ^ CJOJ QJ 2/2 m0 Header CharCJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]   4h 6 qL/!4#&'((2469<?BEGIK ( L &  " p w ~  ? ZP@^ R"%h'( !"#$%&')*+,-./013578:;=>@ACDFHJ!&13!!@ i@ (  VB  C D"?"(g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a C D#" ?2\B d C D#" ?-\B e C D#" ?/\B f C D#" ?1\B g C D#" ?,\B h C D#" ?.\B i C D#" ?0\B j C D#" ?6\B k C D#" ?8\B m C D#" ?=\B n C D#" ?>\B o C D#" ??\B q C D#" ?A\B t C D#" ?C\B u C D#" ?D\B v C D#" ?E\B x C D#" ?@\B y C D#" ?B\B { C D#" ?F\B | C D#" ?GJ"   #" ?3J"   #" ?4J"   #" ?HJ"   #" ?;J"   #" ?9J"   #" ?5J"   #" ?:J"   #" ?IJ"   #" ?<J"   #" ?7hB  c $D#" ?KhB  c $D#" ?LhB  c $D#" ?MhB  c $D#" ?NhB  c $D#" ?OhB  c $D#" ?P\B  C D#" ?JhB  c $D#" ?_hB  c $D#" ?`hB  c $D#" ?ahB  c $D#" ?bhB  c $D#" ?c\B  C D#" ?e\B  C D#" ?dVB  C D"?\B  C D#" ?T\B  C D#" ?UVB  C D"?VVB  C D"?XhB  c $D#" ?QhB  c $D#" ?RhB  c $D#" ?SVB  C D"?YVB  C D"?WVB  C D"?ZVB  C D"?[VB  C D"?]VB  C D"?\VB  C D"?^B S  ?<>~/13yz{    ; < = > k q / = t&ATbw\7Ry3VzJv=V ' e(t(t(t(t(t;(t<(t 8(t"(t#(t$(t%(t'X (t((t)(t8n(n(t6t/t.(t3$t7d(d(t0t-r(tI#&tFtC*t>tH#}&}tEtB}*}t?tJ#&tGtD*t@tAtK 7o'7tLo'tMMo'tOo'tPE o'tQo'tT o'tU<o'tg~'tdth~'teti~'tftam'twtULwt!tj<Rttk-RttrtettmtntotxtqtyhttRtutvXt{2t|>tIt ft & t8B't83't8B't8B't83't8B't8B't8B't8B'tUi$'it$'tQ&t&t &t &tY&tu "&"tY&t&tQ&t3't3't$'t3't3'tQ'tQ'tg*gu]_`bcefhiu     JLow;=ltDFWYenz|T[\_?G]_`bcefhi  333333333333333333333\]u  x7&%d%7&e(7&H*g&U7&yZ7& ^`OJ QJ o(q ^`OJ QJ o(q ^`OJ QJ o(q ^`OJ QJ o(q ^`OJ QJ o(q ^`OJ QJ o(qH*xg&U%d%e(yZ @ @ i & T,|ZO|a*qrCqucz)m9@-PKJ",<KL55;E}]_@  @Unknown G.Cx Times New Roman5Symbol3. .Cx ArialA. Arial Narrow;Wingdings]& Amerigo BTTimes New RomanC  PLucida Grande7.@CalibriK=   jMS Gothic-3 00007@CambriaEMonotype SortsK,Bookman Old StyleA$BCambria Math"hzCG7CIzCG88!24MM`t3QHP ?2! xx ,Health History Questionnaire The Knoblersanne@ppmdom.onmicrosoft.com$      Oh+'0 $0 P \ h t Health History QuestionnaireThe KnoblersNormalanne@ppmdom.onmicrosoft.com5Microsoft Office Word@Ik@ ~@~@B  ՜.+,0 hp  Dell Computer Corporation8M Health History Questionnaire Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLNOPQRSTUWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FP Data M1TableV]WordDocument ژSummaryInformation(DocumentSummaryInformation8MsoDataStore P{ 0OJ3JK23A54G==2 P{ Item  PropertiesUMacrosP{ P{ VBA P{ P{   !"#$%&()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRTUVWXY] 0* pHdProjectQ(@= l 7 J< rstdole>stdoleP f%\*\G{00020430-C 0046}#2.0#0#C:\WINDOWS\SYSTEM\STDOLE2.TLB# Automation ^mMSFo@rms> MSFErm@s/z pFDCB864C3-561C-11D1-9FD3-44455354HF3.TWD#MicrosPoft = ` Ob Libr8ary9P0vP97310C64-4E484P3"PJP\Word8.0dir ThisDocument u_VBA_PROJECT' PROJECT S\ )EX).E .`M CyN@VTalCyNUay , -C @9w6OPfficDO@fPicBG{2DF8D04C-5BFA-101B-BDE5@AA@42gPROGRAM FILES\MICROSOFT OFFICE\MSO97.DLLHl# Jl"BThisDocumentN2@1Th@6sDIcu(en@ HB1ԽB,B"B+BBx5 (S"SS"<(1Normal.ThisDocument0($(* 0ei 8``ME" `lphAttribute VB_Name = "ThisDocument" Bas1Normal.VCreatabl`False PredeclaIdxTru "ExposeTemplate Deriv$CustomizcP08 Sub CheckBox1_Click() End a^  *\G{000204EF-0000-0000-C000-000000000046}#3.0#9#C:\PROGRAM FILES\COMMON FILES\MICROSOFT SHARED\VBA\VBA332.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.0#409#C:\Program Files\Microsoft Office\Office\MSWORD8.OLB#Microsoft Word 8.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\SYSTEM\STDOLE2.TLB#OLE Automation*\G{DCB864C3-561C-11D1-9FD3-444553540000}#2.0#0#C:\WINDOWS\SYSTEM\MSForms.TWD#Microsoft Forms 2.0 Object Library*\G{97310C64-4E84-11D3-9FD3-444553540000}#2.0#0#C:\WINDOWS\TEMP\Word8.0\MSForms.EXD#Microsoft Forms 2.0 Object Library.E .`M *\CNormal*\CNormal9w6 *\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.0#0#C:\PROGRAM FILES\MICROSOFT OFFICE\OFFICE\MSO97.DLL#Microsoft Office 8.0 Object Library7ThisDocument 637b8b0ce*D 7t=SӬio`(&WordkVBAWin16~Win32MacLTA Questionnaire$stdole`MSFormsC ThisDocument< _EvaluateNormalOfficeuProject- CheckBox1DocumentjCheckBox1_Clickl` ID="{953D743A-53F2-11D3-9FD3-AC6917E7176F}" Document=ThisDocument/&H00000000 Name="Project" HelpContextID="0" CMG="EEEC34F65416801A801A801A801A" DPB="2220F8CE2DCF2DCF2D" GC="56548C1AF47A297B297BD6" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 &H00000002={000209F2-0000-0000-C000-000000000046};Word8.0;&H00000000 [Workspace] ThisDocument=22, 22, 305, 284, C @ҋB `ThisDocumentThisDocument  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89qPROJECTlkZPROJECTwm[)CompObj\r