<EMISWebDocTemplate><DisplayGroups></DisplayGroups><DefaultDocumentType></DefaultDocumentType><DocumentTypeCodeSystem></DocumentTypeCodeSystem><Description>Imported item.</Description><TemplateRtf><![CDATA[{\rtf1\adeflang1025\ansi\ansicpg1252\uc1\adeff0\deff0\stshfdbch0\stshfloch31506\stshfhich31506\stshfbi31506\deflang2057\deflangfe2057\themelang2057\themelangfe0\themelangcs0{\fonttbl{\f0\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f2\fbidi \fmodern\fcharset0\fprq1{\*\panose 02070309020205020404}Courier New;}
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{\fbiminor\f31507\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f40\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\f41\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\f43\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\f44\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\f45\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\f46\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
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{\f63\fbidi \fmodern\fcharset161\fprq1 Courier New Greek;}{\f64\fbidi \fmodern\fcharset162\fprq1 Courier New Tur;}{\f65\fbidi \fmodern\fcharset177\fprq1 Courier New (Hebrew);}{\f66\fbidi \fmodern\fcharset178\fprq1 Courier New (Arabic);}
{\f67\fbidi \fmodern\fcharset186\fprq1 Courier New Baltic;}{\f68\fbidi \fmodern\fcharset163\fprq1 Courier New (Vietnamese);}{\f380\fbidi \froman\fcharset238\fprq2 Cambria Math CE;}{\f381\fbidi \froman\fcharset204\fprq2 Cambria Math Cyr;}
{\f383\fbidi \froman\fcharset161\fprq2 Cambria Math Greek;}{\f384\fbidi \froman\fcharset162\fprq2 Cambria Math Tur;}{\f387\fbidi \froman\fcharset186\fprq2 Cambria Math Baltic;}{\f388\fbidi \froman\fcharset163\fprq2 Cambria Math (Vietnamese);}
{\f410\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\f411\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}{\f413\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\f414\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}
{\f415\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}{\f416\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\f417\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}{\f418\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}
{\flomajor\f31508\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\flomajor\f31509\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\flomajor\f31511\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\flomajor\f31512\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flomajor\f31513\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flomajor\f31514\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\flomajor\f31515\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flomajor\f31516\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbmajor\f31518\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\fdbmajor\f31519\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbmajor\f31521\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbmajor\f31522\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\fdbmajor\f31523\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbmajor\f31524\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbmajor\f31525\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fdbmajor\f31526\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhimajor\f31528\fbidi \fswiss\fcharset238\fprq2 Calibri Light CE;}{\fhimajor\f31529\fbidi \fswiss\fcharset204\fprq2 Calibri Light Cyr;}
{\fhimajor\f31531\fbidi \fswiss\fcharset161\fprq2 Calibri Light Greek;}{\fhimajor\f31532\fbidi \fswiss\fcharset162\fprq2 Calibri Light Tur;}{\fhimajor\f31533\fbidi \fswiss\fcharset177\fprq2 Calibri Light (Hebrew);}
{\fhimajor\f31534\fbidi \fswiss\fcharset178\fprq2 Calibri Light (Arabic);}{\fhimajor\f31535\fbidi \fswiss\fcharset186\fprq2 Calibri Light Baltic;}{\fhimajor\f31536\fbidi \fswiss\fcharset163\fprq2 Calibri Light (Vietnamese);}
{\fbimajor\f31538\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbimajor\f31539\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\flominor\f31548\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}
{\flominor\f31549\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\flominor\f31551\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbminor\f31559\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fdbminor\f31561\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbminor\f31562\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}{\fhiminor\f31571\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\fhiminor\f31572\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}
{\fhiminor\f31573\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}{\fhiminor\f31574\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}
{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}{\fbiminor\f31578\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbiminor\f31579\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fbiminor\f31581\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbiminor\f31585\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbiminor\f31586\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}
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{\*\docvar {P6j6BIjFIJgLnCYnxwjy}{P<MergeFieldDetailType UIDisplayName="NHS Number" MergeFieldName="Patient_Identifier_Number" ResourceValue="PrimaryPatientIdentifierShorthandName" />}}
{\*\docvar {Pe1b131NcgdsApPCJsp6}{P<MergeFieldDetailType UIDisplayName="Surname" MergeFieldName="Patient_Surname" />}}{\*\docvar {PgprHnO8iqAYjUcCiV81}{P<MergeFieldDetailType UIDisplayName="Full Name" MergeFieldName="Patient_Full_Name" />}}
{\*\docvar {PgQJdOPSNLXANDaJF9sZ}{P<MergeFieldDetailType UIDisplayName="Full Name" MergeFieldName="Patient_Full_Name" />}}{\*\docvar {PIbr4OhECeIJhfidNIND}{P<MergeFieldDetailType UIDisplayName="Date of Birth" MergeFieldName="Patient_Date_of_Birth" />}}
{\*\docvar {PJ1OoEhwvMfr85e2uSuF}{P<MergeFieldDetailType UIDisplayName="NHS Number" MergeFieldName="Patient_Identifier_Number" ResourceValue="PrimaryPatientIdentifierShorthandName" />}}
{\*\docvar {Pk4OlEwI7toGrHZJpsft}{P<MergeFieldDetailType UIDisplayName="Date of Birth" MergeFieldName="Patient_Date_of_Birth" />}}
{\*\docvar {PlEkgXbK22MUC5HfxuHX}{P<MergeFieldDetailType UIDisplayName="Ethnic Origin" MergeFieldName="Patient_Ethnic_Origin" />}}
{\*\docvar {PLun4fQgRWKXHoOnazOH}{P<MergeFieldDetailType UIDisplayName="NHS Number" MergeFieldName="Patient_Identifier_Number" ResourceValue="PrimaryPatientIdentifierShorthandName" />}}
{\*\docvar {POkmEHiYnZ72cAVoe6Xn}{P<MergeFieldDetailType UIDisplayName="Date of Birth" MergeFieldName="Patient_Date_of_Birth" />}}
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{\*\docvar {PrrnA6vcvu2zN8HLmRDD}{P<MergeFieldDetailType UIDisplayName="Date of Birth" MergeFieldName="Patient_Date_of_Birth" />}}
{\*\docvar {PujZc19ABYSHl3EWOZmW}{P<MergeFieldDetailType UIDisplayName="Ethnic Origin" MergeFieldName="Patient_Ethnic_Origin" />}}{\*\docvar {PULiVjpq6JKHTeB1yU1P}{P<MergeFieldDetailType UIDisplayName="Full Name" MergeFieldName="Patient_Full_Name" />}}
{\*\docvar {PuQzbcStABZhdZfg8ek5}{P<MergeFieldDetailType UIDisplayName="Gender(full)" MergeFieldName="Patient_Gender_Full" />}}
{\*\docvar {PvrubLZ9KMkLqwwdJCga}{P<MergeFieldDetailType UIDisplayName="NHS Number" MergeFieldName="Patient_Identifier_Number" ResourceValue="PrimaryPatientIdentifierShorthandName" />}}
{\*\docvar {PWV2c6eDRwvsdHZPR21M}{P<MergeFieldDetailType UIDisplayName="Home Full Address (stacked)" MergeFieldName="Patient_Contact_Full_Address_Stacked" />}}
{\*\docvar {PXGFqZqsJ4SQDDbbNgJx}{P<MergeFieldDetailType UIDisplayName="Registered GP Full Address (stacked)" MergeFieldName="Patient_Registered_GP_Location_Full_Address_Stacked" />}}
{\*\docvar {PXjmKqeZPiwBSmKUgX3j}{P<MergeFieldDetailType UIDisplayName="Full Name" MergeFieldName="Patient_Full_Name" />}}{\*\docvar {PxqRghWiVqIzOpDIKK9r}{P<MergeFieldDetailType UIDisplayName="Given Name" MergeFieldName="Patient_Given_Name" />}}
{\*\docvar {PySZF6bZ2aImfSdAup3R}{P<MergeFieldDetailType UIDisplayName="Home Full Address (stacked)" MergeFieldName="Patient_Contact_Full_Address_Stacked" />}}
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}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16145020\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 NHS Number:\cell {\*\bkmkstart PLun4fQgRWKXHoOnazOH}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
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\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 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 
\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\tblrsid5443826\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx1588\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7320\clshdrawnil \cellx8908\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16145020\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Address:\cell {\*\bkmkstart PySZF6bZ2aImfSdAup3R}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid15099152\charrsid1339456 {\*\datafield 0002000014000000145079535a4636625a3261496d665364417570335200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PySZF6bZ2aImfSdAup3R}}}}}{\fldrslt {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid15099152\charrsid1339456 Home Full Address (stacked)}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456 
{\*\bkmkend PySZF6bZ2aImfSdAup3R} }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3154049\charrsid1339456  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa160\sl259\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 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 
\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\tblrsid5443826\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx1588\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7320\clshdrawnil \cellx8908\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16145020\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Gender: \cell {\*\bkmkstart PRiH1ZAktwdVYnLkOWp5}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid15099152\charrsid1339456 {\*\datafield 00020000140000001450526948315a416b74776456596e4c6b4f57703500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PRiH1ZAktwdVYnLkOWp5}}}}}{\fldrslt {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid15099152\charrsid1339456 Gender(full)}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456 
{\*\bkmkend PRiH1ZAktwdVYnLkOWp5} }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3154049\charrsid1339456  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa160\sl259\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 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 
\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\tblrsid5443826\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx1588\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7320\clshdrawnil \cellx8908\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16145020\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Ethnicity*:\cell {\*\bkmkstart PlEkgXbK22MUC5HfxuHX}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid15099152\charrsid1339456 {\*\datafield 000200001400000014506c456b6758624b32324d55433548667875485800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlEkgXbK22MUC5HfxuHX}}}}}{\fldrslt {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid15099152\charrsid1339456 Ethnic Origin}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456 
{\*\bkmkend PlEkgXbK22MUC5HfxuHX} }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2378983\charrsid1339456  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa160\sl259\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 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 
\trowd \irow5\irowband5\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\tblrsid5443826\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1696\clshdrawnil \cellx1588\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7320\clshdrawnil \cellx8908\row 
}\pard \ltrpar\ql \li0\ri0\sa160\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16145020 {\rtlch\fcs1 \af37 \ltrch\fcs0 \ul\insrsid16145020\charrsid1339456 
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\ul\insrsid5443826\charrsid1339456 GP Practice
\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\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid788277\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx2552\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6356\clshdrawnil \cellx8908
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16145020\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Address:\cell {\*\bkmkstart PXGFqZqsJ4SQDDbbNgJx}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid15099152\charrsid1339456 {\*\datafield 00020000140000001450584746715a71734a345351444462624e674a7800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PXGFqZqsJ4SQDDbbNgJx}}}}}{\fldrslt {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid15099152\charrsid1339456 Registered GP Full Address (stacked)}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15099152\charrsid1339456 
{\*\bkmkend PXGFqZqsJ4SQDDbbNgJx} }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5589575\charrsid1339456  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa160\sl259\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 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 
\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\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid788277\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx2552\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6356\clshdrawnil \cellx8908
\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16145020\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Referring GP:\cell {\*\bkmkstart Text19}}{\field{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid5383158  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid5383158 {\*\datafield 
00000000140000000654657874313900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text19}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \b\lang1024\langfe1024\noproof\insrsid5383158 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194
\'20}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 {\*\bkmkend Text19}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa160\sl259\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 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 
\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\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid788277\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx2552\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6356\clshdrawnil \cellx8908
\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16145020\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Does your Practice serve a deprived population?*:\cell }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid9983920\charrsid1339456 Yes}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9983920\charrsid1339456  
{\*\bkmkstart Check1}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9983920\charrsid1339456  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9983920\charrsid1339456 {\*\datafield 
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9983920\charrsid1339456 {\*\bkmkend Check1}  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid9983920\charrsid1339456 No}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9983920\charrsid1339456  {\*\bkmkstart Check2}}
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9983920\charrsid1339456  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9983920\charrsid1339456 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid5443826\charrsid1339456 {\*\bkmkend Check2}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa160\sl259\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 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 \trowd \irow2\irowband2\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\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid788277\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth2660\clshdrawnil \cellx2552\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6356\clshdrawnil \cellx8908
\row }\pard \ltrpar\ql \li0\ri0\sa160\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16145020 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16145020\charrsid1339456 *National requirement for data collection
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Date of referral:}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9983920\charrsid1339456   {\*\bkmkstart RPqnk9JqXbSWaStuFJYQ}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid6309804\charrsid1339456  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid6309804\charrsid1339456 {\*\datafield 0002000014000000145250716e6b394a715862535761537475464a595100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname RPqnk9JqXbSWaStuFJYQ}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid6309804\charrsid1339456 Referral Date}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid6309804\charrsid1339456 {\*\bkmkend RPqnk9JqXbSWaStuFJYQ} }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 
\par Prior to referral to the Post Covid Syndrome MDT, please complete the following:
\par {\listtext\pard\plain\ltrpar \s16 \rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f31506\fs22\insrsid5443826\charrsid1339456 \hich\af31506\dbch\af0\loch\f31506 1.\tab}}\pard\plain \ltrpar
\s16\ql \fi-360\li720\ri0\sa160\widctlpar\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid16145020\contextualspace \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 GP follow up advice sheet has been utilised and symptoms investigated and treated as appropriate
\par {\listtext\pard\plain\ltrpar \s16 \rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \f31506\fs22\insrsid5443826\charrsid1339456 \hich\af31506\dbch\af0\loch\f31506 2.\tab}
Complete and attach the C-19 Yorkshire Rehabilitation Screening Tool (as recommended by NICE). Referrals will be rejected if this is not complete.
\par }\pard\plain \ltrpar\ql \li0\ri0\sa160\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16145020 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f31506\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Date of initial symptoms:}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9269950\charrsid1339456  {\*\bkmkstart Text18}}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9269950\charrsid1339456 
 FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9269950\charrsid1339456 {\*\datafield 00000000140000000654657874313800000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text18}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang1024\langfe1024\noproof\insrsid7366721\charrsid1339456 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid5443826\charrsid1339456 {\*\bkmkend Text18}
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 Positive PCR in the community?}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456       }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid2455214\charrsid1339456 Yes}{\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid2455214\charrsid1339456  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456 {\*\datafield 
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456   }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid2455214\charrsid1339456 No}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid2455214\charrsid1339456  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4219657\charrsid1339456 
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid5443826\charrsid1339456 If No, strong clinical suspicion of Covid-19?}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456       }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid2455214\charrsid1339456 Yes}{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456 {\*\datafield 
650000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456   }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid2455214\charrsid1339456 No}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid2455214\charrsid1339456  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2455214\charrsid1339456 {\*\datafield 650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname 
Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5443826\charrsid1339456 
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\ul\insrsid5443826\charrsid1339456 Clinical History:
\par }\pard \ltrpar\ql \li0\ri0\sa160\widctlpar\brdrt\brdrs\brdrw10\brsp20 \brdrl\brdrs\brdrw10\brsp80 \brdrb\brdrs\brdrw10\brsp20 \brdrr\brdrs\brdrw10\brsp80 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3884830 {\*\bkmkstart Text2}
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4219657\charrsid1339456  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4219657\charrsid1339456 {\*\datafield 000000001400000005546578743200000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text2}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid7366721\charrsid1339456 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16145020\charrsid1339456 {\*\bkmkend Text2}
\par }\pard \ltrpar\ql \li0\ri0\sa160\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16145020 {\rtlch\fcs1 \af37 \ltrch\fcs0 \b\ul\insrsid16145020\charrsid1339456 Relevant investigations and results:
\par }\pard \ltrpar\ql \li0\ri0\sa160\widctlpar\brdrt\brdrs\brdrw10\brsp20 \brdrl\brdrs\brdrw10\brsp80 \brdrb\brdrs\brdrw10\brsp20 \brdrr\brdrs\brdrw10\brsp80 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3884830 {\*\bkmkstart Text3}
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4219657\charrsid1339456  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4219657\charrsid1339456 {\*\datafield 000000001400000005546578743300000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text3}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid7366721\charrsid1339456 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16145020\charrsid1339456 {\*\bkmkend Text3}
\par }\pard \ltrpar\ql \li0\ri0\sa160\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16145020 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16145020\charrsid1339456 
\par }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5383158 {\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid4009532\charrsid1339456 
\par }\pard \ltrpar\ql \li0\ri0\sa160\sl259\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid4009532 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4009532\charrsid1339456 
\par }\pard \ltrpar\ql \li0\ri0\sa160\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16145020 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4009532\charrsid1339456 
\par }{\*\themedata 504b030414000600080000002100e9de0fbfff0000001c020000130000005b436f6e74656e745f54797065735d2e786d6cac91cb4ec3301045f748fc83e52d4a

0000000000000000db0900007468656d652f7468656d652f5f72656c732f7468656d654d616e616765722e786d6c2e72656c73504b050600000000050005005d010000d60a00000000}
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