The examination form: you may fill in all the questions that ____ to you. If you don't know exactly how to answer a question, leave it ____, the doctor will go over all the questions with you so you will come to a ____ together. If the question does not apply to you, you may leave it blank. On the back answer the two ____ questions and date and ____ it. Check your personal information, if ____ have it changed at the examination.

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