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{\sp{\sn fAllowOverlap}{\sv 1}}{\sp{\sn fBehindDocument}{\sv 0}}{\sp{\sn fHidden}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 1}}}{\shprslt}}}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15029726
\par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}
{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8
\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid15029726 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\ul\insrsid15029726
\par }\pard \ltrpar\qc \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14965068 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 GP Referral to }{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid15732425\charrsid14965068 Adult }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 Sleep }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid11758809\charrsid14965068
Disordered Breathing }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 Clinic}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid15732425\charrsid14965068 Royal Free London NHS Trust}{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f1\fs20\ul\insrsid14831007\charrsid14965068
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid11758809 {\rtlch\fcs1 \af1\afs19 \ltrch\fcs0 \f1\fs19\insrsid11758809\charrsid14965068 Dear Colleague,
\par Please complete the referral form below for all referrals to the Royal Free London Sleep Disordered Breathing clinic.}{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0 \f1\fs19\insrsid12942159\charrsid14965068 Please note that we }{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0
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y sleep disorders (for example i}{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0 \f1\fs19\insrsid12942159\charrsid14965068 nsomnia, }{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0 \f1\fs19\insrsid7502723\charrsid14965068 narcolepsy}{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0
\f1\fs19\insrsid12942159\charrsid14965068 ,}{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0 \f1\fs19\insrsid7502723\charrsid14965068 parasomnias}{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0 \f1\fs19\insrsid12942159\charrsid14965068 etc.}{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0
\f1\fs19\insrsid7502723\charrsid14965068 .}{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0 \f1\fs19\insrsid12942159\charrsid14965068 .) }{\rtlch\fcs1 \af1\afs19 \ltrch\fcs0 \f1\fs19\insrsid11758809\charrsid14965068
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid8667198 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 Patient Information:
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\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2995\clshdrawnil \cellx6823\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
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\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 Surname\cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681
{\*\bkmkstart PrLvYIUup9rzGXY15dMe} FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 00020000140000001450724c76594955757039727a4758593135644d6500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname PrLvYIUup9rzGXY15dMe}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 Surname}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend PrLvYIUup9rzGXY15dMe} }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 NHS Number\cell }
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkstart PEkvPu15A8Bp74E1EsGP} FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
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\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend PEkvPu15A8Bp74E1EsGP} }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
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\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2311\clshdrawnil \cellx9134\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1
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\b\f1\fs20\insrsid8667198\charrsid14965068 First Name\cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkstart PWufGx3rS7L2eXAbRJ3W} FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681
{\*\datafield 000200001400000014505775664778337253374c3265584162524a335700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PWufGx3rS7L2eXAbRJ3W}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681
Calling Name}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend PWufGx3rS7L2eXAbRJ3W} }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 MRN (if available)\cell }{\field{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681
{\*\bkmkstart Text1} FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 000000001400000005546578743100000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text1}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\lang1024\langfe1024\noproof\insrsid723681 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 {\*\bkmkend Text1}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025
\ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068 \trowd \irow1\irowband1\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
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\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2995\clshdrawnil \cellx6823\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2311\clshdrawnil \cellx9134\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025
\ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 D.O.B\cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0
\cs16\insrsid723681\charrsid723681 {\*\bkmkstart PS8dpZ5UuQtFjV6Xc9hD} FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \cs16\insrsid723681\charrsid723681 {\*\datafield 00020000140000001450533864705a3555755174466a5636586339684400000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PS8dpZ5UuQtFjV6Xc9hD}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs16\insrsid723681\charrsid723681 Date of Birth}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs16\insrsid723681\charrsid723681 {\*\bkmkend PS8dpZ5UuQtFjV6Xc9hD} }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid8667198\charrsid723681 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 Date of referral\cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681
{\*\bkmkstart dxmslZReSeMpq7lkRHO1} FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 00020000140000001464786d736c5a526553654d7071376c6b52484f3100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname dxmslZReSeMpq7lkRHO1}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 Short date letter merged}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend dxmslZReSeMpq7lkRHO1} }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid723681 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068
\trowd \irow2\irowband2\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1668\clshdrawnil \cellx1560\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2268\clshdrawnil \cellx3828\clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2995\clshdrawnil \cellx6823\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2311\clshdrawnil \cellx9134\row \ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts15\trgaph108\trrh624\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1668\clshdrawnil \cellx1560\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth7574\clshdrawnil \cellx9134\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 Address\cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681
{\*\bkmkstart Pmi5DgoYUXrEWhzWcVIC} FORMTEXT }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 000200001400000014506d693544676f595558724557687a576356494300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname Pmi5DgoYUXrEWhzWcVIC}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 Home Full Address (single line)}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj
{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend Pmi5DgoYUXrEWhzWcVIC} }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068
\trowd \irow3\irowband3\lastrow \ltrrow\ts15\trgaph108\trrh624\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1668\clshdrawnil \cellx1560\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7574\clshdrawnil \cellx9134\row
}\pard \ltrpar\ql \li0\ri0\sa120\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid11758809 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid11758809\charrsid14965068
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpara\phmrg\posy495\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15029726\yts15
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 Does the patient snore loudly?\cell }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681 Yes }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkstart Check1} FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend Check1} No }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 {\*\bkmkstart Check2} FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2
}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid15029726\charrsid723681 {\*\bkmkend Check2}\cell
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0
\ltrch\fcs0 \insrsid15029726\charrsid14965068 \trowd \irow0\irowband0\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpara\phmrg\posy495\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15029726\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 Does the patient feel tired or sleepy during the day?\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid15029726\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid15029726\charrsid14965068 \trowd \irow1\irowband1\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpara\phmrg\posy495\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15029726\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 Has anyone observed the patient stop breathing during their sleep?\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid15029726\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid15029726\charrsid14965068 \trowd \irow2\irowband2\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpara\phmrg\posy495\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15029726\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 Is the patient being treated for hypertension?\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid15029726\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid15029726\charrsid14965068 \trowd \irow3\irowband3\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\row \ltrrow}\trowd \irow4\irowband4\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid723681\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1128\clshdrawnil \cellx7655\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1666\clshdrawnil \cellx9321\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpara\phmrg\posy495\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15029726\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 BMI >35kg/m}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\super\insrsid15029726\charrsid14965068 2}{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 ?\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681
}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\ul\insrsid15029726\charrsid14965068 \cell }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \insrsid723681\charrsid723681 {\*\bkmkstart T5gRn8AYWdJxtWjtxQT8} FORMTEXT }{\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \insrsid723681\charrsid723681
{\*\datafield 000200001400000014543567526e38415957644a7874576a747851543800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname T5gRn8AYWdJxtWjtxQT8}}}}}{\fldrslt {\rtlch\fcs1 \ab\af0 \ltrch\fcs0
\insrsid723681\charrsid723681 BMI}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \ab\af0 \ltrch\fcs0 \insrsid723681\charrsid723681 {\*\bkmkend T5gRn8AYWdJxtWjtxQT8}\cell
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0
\ltrch\fcs0 \insrsid15029726\charrsid14965068 \trowd \irow4\irowband4\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid723681\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth1128\clshdrawnil \cellx7655\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1666\clshdrawnil \cellx9321\row \ltrrow
}\trowd \irow5\irowband5\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpara\phmrg\posy495\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15029726\yts15
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 Age >50 years old?\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid15029726\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid15029726\charrsid14965068 \trowd \irow5\irowband5\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts15\trgaph108\trrh318\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid723681\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\pvpara\phmrg\posy495\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15029726\yts15 \rtlch\fcs1
\af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 Neck circumference> 16 inches (40cm)?\cell }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid15029726\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid15029726\charrsid14965068 \trowd \irow6\irowband6\ltrrow\ts15\trgaph108\trrh318\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid723681\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\row \ltrrow}\trowd \irow7\irowband7\lastrow \ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10
\trbrdrv\brdrs\brdrw10 \tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\pvpara\phmrg\posy495\dxfrtext180\dfrmtxtx180\dfrmtxty0\wraparound\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15029726\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid15029726\charrsid14965068 Male Gender?\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681 Yes }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid15029726\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15029726\charrsid14965068
\trowd \irow7\irowband7\lastrow \ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\tpvpara\tphmrg\tposy495\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth3\trwWidth9429\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15029726\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6635\clshdrawnil \cellx6527\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr
\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2794\clshdrawnil \cellx9321\row }\pard \ltrpar\ql \li0\ri0\sa120\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid11758809 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\f1\fs20\ul\insrsid8667198\charrsid14965068 Screening questions: }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\ul\insrsid8667198\charrsid14965068 (please answer yes or no to the following questions)
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid11758809\charrsid14965068
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 Epworth Sleepiness Score:
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068
How likely is the patient likely to doze off or fall asleep in the following situations, in comparison to feeling just tired? Use the following scale to choose the most appropriate number for each situation:}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid11758809\charrsid14965068
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 0 = would never doze
\par 1 = slight chance of dozing
\par 2 = moderate chance of dozing
\par 3 = high chance of dozing
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 Situation\cell Chance of dozing (0=low, 3=high)\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068 \trowd \irow0\irowband0\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10
\trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid8667198\charrsid14965068 Sitting and reading\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 0 }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681
{\*\bkmkstart Check3} FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check3}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend Check3} 1 }{\field\fldpriv{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkstart Check4} FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 {\*\bkmkend Check4} 2 }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkstart Check5} FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend Check5} 3 }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 {\*\bkmkstart Check6} FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check6
}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\bkmkend Check6} }{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068 \trowd \irow1\irowband1\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid8667198\charrsid14965068 Watching TV\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 0 }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 2 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check5}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 3 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check6}
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid8667198\charrsid14965068 \trowd \irow2\irowband2\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid8667198\charrsid14965068 Sitting still in a public place (e.g. theatre, cinema or a meeting \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 0 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 1 }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 2 }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 3 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068
\trowd \irow3\irowband3\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow
}\trowd \irow4\irowband4\ltrrow\ts15\trgaph108\trrh447\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid723681\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid8667198\charrsid14965068 As a passenger in a car for an hour without a break\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 0 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check3}
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 2 }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 3 }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068 \trowd \irow4\irowband4\ltrrow\ts15\trgaph108\trrh447\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid723681\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow
}\trowd \irow5\irowband5\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid8667198\charrsid14965068 Lying down to rest in the afternoon when the circumstances allow\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 0 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 1 }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 2 }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 3 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068
\trowd \irow5\irowband5\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid8667198\charrsid14965068 Sitting and talking to someone\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 0 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check3}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 2 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 3 }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0
\ltrch\fcs0 \insrsid8667198\charrsid14965068 \trowd \irow6\irowband6\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid8667198\charrsid14965068 Sitting quietly after lunch without having drunk alcohol\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 0 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check3}
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 2 }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 3 }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3600000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068 \trowd \irow7\irowband7\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10
\cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \i\f1\fs20\insrsid8667198\charrsid14965068 In a car or bus while stopped for a few minutes in traffic\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 0 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 1 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 2 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check5}
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 3 }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid8667198\charrsid14965068 \trowd \irow8\irowband8\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11758809\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 TOTAL\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068
\trowd \irow9\irowband9\lastrow \ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11758809\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5778\clshdrawnil \cellx5670\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3261\clshdrawnil \cellx8931\row
}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\ul\insrsid14965068 \page
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl-200\slmult0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid8667198 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068
Is the patient currently being investigated or treated for any of the following conditions?
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\ul\insrsid8667198\charrsid14965068 (}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\ul\insrsid11758809\charrsid14965068 P}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\b\i\f1\fs20\ul\insrsid8667198\charrsid14965068 lease answer yes or no)
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134
\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5904242\charrsid14965068 Ischaemic heart disease}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid8667198\charrsid14965068 \trowd \irow0\irowband0\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5904242\charrsid14965068 Diabetes mellitus}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid8667198\charrsid14965068 \trowd \irow1\irowband1\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5904242\charrsid14965068 Atrial fibrillation}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid8667198\charrsid14965068 \trowd \irow2\irowband2\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5904242\charrsid14965068 Hypothyroidism}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681
Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8667198\charrsid14965068
\trowd \irow3\irowband3\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5904242\charrsid14965068 Cerebrovascular disease}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8667198\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid8667198\charrsid14965068 \trowd \irow4\irowband4\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5904242\charrsid14965068 Epilepsy}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid8670661\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681 Yes }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8670661\charrsid14965068 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8670661\charrsid14965068
\trowd \irow5\irowband5\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8667198\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid2060762\charrsid14965068 Neuromuscular Disease (e.g. MND)}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid11758809\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid11758809\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid11758809\charrsid14965068 \trowd \irow6\irowband6\lastrow \ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8667198\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row
}\pard \ltrpar\ql \li0\ri0\sa200\sl360\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12336457 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid8667198\charrsid14965068
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12942159\charrsid14965068 We currently triage urgent referrals i}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid5904242\charrsid14965068 n accordance with NICE guidance:}{\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5904242\charrsid14965068 }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid12942159\charrsid14965068 (https://www.nice.org.uk/guidance/ng202/)
\par \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14757135\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12942159\charrsid14965068 Is the patient an occupational driver?\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\ul\insrsid12942159\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid12942159\charrsid14965068 \trowd \irow0\irowband0\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14757135\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14757135\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12942159\charrsid14965068 Is the patient currently pregnant?\cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname
Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid12942159\charrsid14965068 \cell
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0
\ltrch\fcs0 \insrsid12942159\charrsid14965068 \trowd \irow1\irowband1\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14757135\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14757135\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12942159\charrsid14965068 Is the patient undergoing pre-operative assessment for major surgery}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5904242\charrsid14965068 ?}{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f1\fs20\insrsid12942159\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid12942159\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid12942159\charrsid14965068 \trowd \irow2\irowband2\ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14757135\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14757135\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid12942159\charrsid14965068 Do they have non-arteritic anterior ischaemic optic neuropathy}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\f1\fs20\insrsid5904242\charrsid14965068 ?}{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\f1\fs20\insrsid12942159\charrsid14965068 \cell }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid723681 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid723681 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\ul\insrsid12942159\charrsid14965068 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0
\insrsid12942159\charrsid14965068 \trowd \irow3\irowband3\lastrow \ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14757135\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx4513\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4621\clshdrawnil \cellx9134\row
}\pard \ltrpar\ql \li0\ri0\sa200\sl360\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5904242 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid5904242\charrsid14965068
\par Please attach a list of medication}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid2383953\charrsid14965068 s}{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid5904242\charrsid14965068 and current co-morbidities}{\rtlch\fcs1 \af1\afs20
\ltrch\fcs0 \b\i\f1\fs20\insrsid5904242
\par }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \ab\ai\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4850273\charrsid4850273 {\*\bkmkstart T7FWhiaYHdtEyip7sows} FORMTEXT }{\rtlch\fcs1 \ab\ai\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4850273\charrsid4850273 {\*\datafield
00020000140000001454374657686961594864744579697037736f777300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname T7FWhiaYHdtEyip7sows}}}}}{\fldrslt {\rtlch\fcs1 \ab\ai\af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid4850273\charrsid4850273 Medication}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \ab\ai\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid4850273\charrsid4850273
{\*\bkmkend T7FWhiaYHdtEyip7sows}
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl360\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12336457 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid12336457\charrsid14965068
\par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw20\brdrcf6 \trbrdrl\brdrs\brdrw20\brdrcf6 \trbrdrb\brdrs\brdrw20\brdrcf6 \trbrdrr\brdrs\brdrw20\brdrcf6 \trbrdrh\brdrs\brdrw20\brdrcf6 \trbrdrv
\brdrs\brdrw20\brdrcf6 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9964936\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf6 \clbrdrl
\brdrs\brdrw20\brdrcf6 \clbrdrb\brdrs\brdrw20\brdrcf6 \clbrdrr\brdrs\brdrw20\brdrcf6 \cltxlrtb\clftsWidth3\clwWidth9242\clshdrawnil \cellx9134\pard\plain \ltrpar\ql \li0\ri0\sl360\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12336457\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid2884233\charrsid14965068
Please inform the patient that they may be contacted by the sleep and ventilation team to arrange testing prior to an appointment. The sleep service is very busy and if the patient is not contactable or they do not undertake the testing within a pre-spec
ified period, they will be discharged and require a re-referral.\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0
\f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2884233\charrsid14965068 \trowd \irow0\irowband0\lastrow \ltrrow\ts15\trgaph108\trleft-108\trbrdrt\brdrs\brdrw20\brdrcf6 \trbrdrl\brdrs\brdrw20\brdrcf6
\trbrdrb\brdrs\brdrw20\brdrcf6 \trbrdrr\brdrs\brdrw20\brdrcf6 \trbrdrh\brdrs\brdrw20\brdrcf6 \trbrdrv\brdrs\brdrw20\brdrcf6
\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9964936\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20\brdrcf6 \clbrdrl\brdrs\brdrw20\brdrcf6 \clbrdrb
\brdrs\brdrw20\brdrcf6 \clbrdrr\brdrs\brdrw20\brdrcf6 \cltxlrtb\clftsWidth3\clwWidth9242\clshdrawnil \cellx9134\row }\pard \ltrpar\ql \li0\ri0\sa200\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5904242 {\rtlch\fcs1
\af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid5904242\charrsid14965068
\par Please confirm that the patient has been informed about the referral: }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11166767 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11166767\charrsid723681 Yes }{\field\flddirty\fldpriv{\*\fldinst {
\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11166767 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11166767 {\*\datafield 650000001400000006436865636b3100000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid11166767 No }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11166767 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11166767 {\*\datafield
650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sectrsid9964936\sftnbj {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid11166767\charrsid11166767 }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0
\f1\fs20\insrsid5904242\charrsid14965068
\par }\pard \ltrpar\ql \li0\ri0\sa200\sl360\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12336457 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \b\i\f1\fs20\insrsid5904242\charrsid14965068
\par
\par }\pard \ltrpar\qc \li0\ri0\sa200\sl360\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12336457 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid14235949\charrsid14965068
\par }{\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f1\fs20\insrsid13006504\charrsid14965068 Thank you
\par }{\*\themedata 504b030414000600080000002100e9de0fbfff0000001c020000130000005b436f6e74656e745f54797065735d2e786d6cac91cb4ec3301045f748fc83e52d4a
9cb2400825e982c78ec7a27cc0c8992416c9d8b2a755fbf74cd25442a820166c2cd933f79e3be372bd1f07b5c3989ca74aaff2422b24eb1b475da5df374fd9ad
5689811a183c61a50f98f4babebc2837878049899a52a57be670674cb23d8e90721f90a4d2fa3802cb35762680fd800ecd7551dc18eb899138e3c943d7e503b6
b01d583deee5f99824e290b4ba3f364eac4a430883b3c092d4eca8f946c916422ecab927f52ea42b89a1cd59c254f919b0e85e6535d135a8de20f20b8c12c3b0
0c895fcf6720192de6bf3b9e89ecdbd6596cbcdd8eb28e7c365ecc4ec1ff1460f53fe813d3cc7f5b7f020000ffff0300504b030414000600080000002100a5d6
a7e7c0000000360100000b0000005f72656c732f2e72656c73848fcf6ac3300c87ef85bd83d17d51d2c31825762fa590432fa37d00e1287f68221bdb1bebdb4f
c7060abb0884a4eff7a93dfeae8bf9e194e720169aaa06c3e2433fcb68e1763dbf7f82c985a4a725085b787086a37bdbb55fbc50d1a33ccd311ba548b6309512
0f88d94fbc52ae4264d1c910d24a45db3462247fa791715fd71f989e19e0364cd3f51652d73760ae8fa8c9ffb3c330cc9e4fc17faf2ce545046e37944c69e462
a1a82fe353bd90a865aad41ed0b5b8f9d6fd010000ffff0300504b0304140006000800000021006b799616830000008a0000001c0000007468656d652f746865
6d652f7468656d654d616e616765722e786d6c0ccc4d0ac3201040e17da17790d93763bb284562b2cbaebbf600439c1a41c7a0d29fdbd7e5e38337cedf14d59b
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