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Hello and welcome to Exuberant Lives. Please fill out this Confidential Health Record. It will take approximately 20 minutes to complete the questionnaire. Your information will be strictly confidential.

Please start with the survey now by clicking on the Continue button below.
 
 
 
Name
   
 
 
 
Address
   
 
 
 
Email Address
   
 
 
 
Phone Number
   
 
 
 
Occupation
   
 
 
 
How long have you worked here?
   
 
 
 
Age
   
 
 
 
Marital Status
 
Single
 
Married
 
Divorced
 
Widowed
 
Common-law
 
Other
 
 
 
 
Do you have children?
 
yes
 
no