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PatientInformationForm DATE: NAME: BIRTHDATE: MALE FEMALE ADDRESS: EMAIL: HOMOPHONE:() WORKSHOP:() CELLPHONE:() CHECKALLTHATAPPLY:Single Married Widow(er) Student SOCIALSECURITY# EMPLOYER: ADDRESS:
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Check all that apply for single, married, widower, or student is a section typically found in surveys or forms that allows individuals to indicate their current marital or student status.
Individuals applying for certain benefits, tax forms, or surveys may be required to indicate their status as single, married, widower, or student.
To fill it out, simply check the boxes that apply to your current status: single, married, widower, or if you are a student.
The purpose is to gather relevant demographic information that may affect eligibility for programs, benefits, or to analyze data based on marital and educational status.
You must report your current marital status (single, married, widower) and whether you are a student.
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