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Cas 103 E 2011-2023
Please complete and sign this form and provide copies of any medical records that would be relevant to making this determination. Date of Client s Last Medical Visit Current Medical and Mental Health Conditions Do any of the above conditions affect the client s ability to 1. Travel to appointments Yes No 2. Take public transportation 3. Travel outside of the home without a companion 4. Attend medical or other appointments 5. Go food shopping or handle other routine errands If you answered Yes...
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