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ADULT HEALTH HISTORY (13 years and older) Confidential Information FormGeneral Information:Today's Date: ___Name:___DOB: ___ Address:___City___State___Zip___ Phone:___Occupation:___ Email: ___Referred
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What is note that this is?
Note that this is is a document used to report specific information.
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Taxpayers with the specific information that needs to be reported.
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Fill out the form with accurate and complete information.
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The purpose is to provide the necessary information to the relevant authorities.
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