Organization: 2     Site: 3     Form ID: 15162
Clinician ID: 10

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Looking back at the past two weeks, select how often you...



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frowny face


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Very
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frowny face


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Very
Often
frowny face


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Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face


Never
smiley face
       
Very
Often
frowny face

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