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First Visit Questionnaire

Identifying Information - Face Sheet

4. IDENTIFYING INFORMATION
Height
Sex (Gender) *This question is required.
This question requires a valid date format of MM/DD/YYYY.
calendar
Handedness
5. Work/Employment
Monthly Household Income
6. Marital Status
8. Is it ok for us to contact that person?
9. Did you serve in the military? *This question is required.
How did you enter? *This question is required.
Did you see combat? *This question is required.
Were you a POW? *This question is required.
Do you have a service connected disability? *This question is required.
What %? *This question is required.