{"text":"I =dlUb. VLN \nLU i3 \ne \u2014\u2014 - - \n| \nAlcohol Issucs: (canzumplion deva <, cffest on offender\/achar our? \n- \nL e 2 O\u2018C\u2019Q\u00ab\\\u2019On\ufb02q -~ eXLeRT G- CaniSimi i) , \nWAM PGRS \u2014 gy T B GOREDS VG \nDrug lasucs: {consumption details, cfec| of o\ufb02\u2019cnderfbehawout) \nI. Are you dependent on drugs? 1l yes, sive dewasls ND \n1. Have you taken any illcgal drugs in the past three months? \u00a3 yes, give delails b{ \n(CSTRASY tHisH @5 \n\/ \n3. Arc you on prescribed methadane? If yes, dosage M \no \nMental Health [ssues: \nNene Refreigo \nACCESS TO MEDICAL REPORTS \n{t may be necessary to gbtawn o tepor from a goclor who has Geared you We are required 1o tell you sbowt your \nstatutory rights regarding sccess (0 medical report, which ace set out bnefly below You may: \n(2} refuse to allow us to obain & report; \n\u00ae) ask (o sco @ report before it s sont 1o us, or, for a charge, obtain a copy from the doctor within six \nmonths of it being sent to us; \n(\u00a2) Ask for \u00bb report you have scen 10 be aliered by the doctor before it is sest 1o us, or, if the doctor I \nunwilling to do this, you may add sistement of your own \nPlease note that the doctor does not have to let you see s report 1 he balieves you or others might be harmed by . \nDECLARATION \n['confiem that [ have ead about my rights under the Access to Medical Repocts Aet and \n1 authorise\/do not aothortse my doctor 10 provide a medical report \n[ wish\/*do not wish to see any medicat report beforc it js supplied. \n(*delete as mppropriate) \n[ declure that all the information 2 have g+ven n this form is true and that [ have not witkheld any material fact. \n;i;nnurc: \" f ,D \ufb02g\/\/\/z\/\u2014-\u2014\u2014\u2014-\u2014 Date: \/C-\/l\/ Z\u00e9)? \n1 am declaring that the sbove facts are stif! wue Ifu{r: have been any changes, | must complete 2 new form. \nStart Of Course \nSignatyre: Date: \nM Cllargmben Cemire. Alvagtun, Wizgus Uimarkalimy 8112 B30, \nFomm) s o macs 000 3y an ik, Fetbmimy 1 o m arrmnnan e \u00a2 o sk \nFel R 31} 1N Tas Hisnd Sod ol \nAITKBUKXE INDIERTLOE leL:UI8bdaUL0a] F 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