Pain / ANY CHRONIC PAIN YOU MAY EXPERIENCE CHECK ANY OF THE MEDICAL CONDITIONS BELOW WHICH YOU HAVE HAD *IN10 BIOPSYCHOSOCIAL ASSESSMENT* Chronic headaches Chronic / HIV / AIDS High blood pressure Chest pain Bronchitis Hearing loss GYN / addiction treatment TREATMENT ACCEPTANCE LEVEL Withdrawal symptoms / ALL THAT APPLY Depressed mood Nausea / /
Organization
World Health Organization / OR BE / Depression School / /
Position
counselor / BIRTH MEDICAL RECORD NUMBER BIOMEDICAL SCREENING LIST YOUR PSYCHIATRIST / /
Product
program INPATIENT Severe / Valium / PATIENT INFORMED OF NEED FOR PHYSICAL EXAMINATION LEVEL OF CARE RECOMMENDATION OUTPATIENT No / No / Xanax / addiction treatment TREATMENT ACCEPTANCE LEVEL / NICOTINE / /
Chemical Dependency Center INTENSIVE OUTPATIENT PROGRAM BIOPSYCHOSOCIAL ASSESSMENT PATIENT LABEL