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Instructions abt cond 12Mo
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Instr ease understand 12Mo
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How oft desc foll instr 12Mo
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Fill sign form 12Mo
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How oft help fill form 12Mo
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How oft explain underst 12Mo
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How oft listen 12Mo
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How oft respect say 12Mo
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How oft spend enough time 12Mo
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Appnt see specialist 12Mo
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How oft appoint as need 12Mo
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Date form completed
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{mm/dd/yyyy}
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Who comp form
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Rship person on form
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