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General Information
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Previous Polygraph Examination :
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Explain
List all current medical/physical conditions :
Any Current Discomfort :
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Describe
Are you pregnant :
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Have you eaten in the last 24 hours :
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Time you went to bed :
Time you got up :
How did you sleep :
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Major injury/surgery within the last 6 months :
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Do you currently have heart problems :
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No
Do you have any communicable diseases now :
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No
Have high/low blood pressure :
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Do you have seizures :
Yes
No
Do You Have Trouble hearing :
Yes
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Currently having back pain :
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Alcohol in last 24 hours :
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list all medications that are currently prescribed to you :
Ever seen apsychologis to rpsychiatrist :
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Any illegal drugs consumed in last 24/48 hours :
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Please list the drugs taken, how much and when :
Ever been a patient in a mental hospital :
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Have you ever been diagnosed with or treated for: Depression :
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Have you ever been diagnosed with or treated for: Schizophrenia :
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Bipolar Disorder :
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Panic/Stress Disorder :
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Obsessive Compulsive Disorder :
Yes
No
Alcohol Dependence :
Yes
No
Drug Addiction :
Yes
No
Any Eating Disorder :
Yes
No
Any form of Personality Disorder :
Yes
No
Posttraumatic Stress Disorder:
Yes
No
Phobias :
Yes
No