expoweb/years/2007/Expo07frm.rtf

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\s16\qc \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs28\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Cambridge Austrian Cave Science Expedition 2007
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\par The prompt return of a paper copy of this form is encouraged.  The deadline for this is Friday 1}{\super st}{ June.  Please enclose a deposit cheque for \'a3
 120 (payable to CU Caving Club Expo), unless you are to incur a large expo expense in advance of the trip (e.g. ferry tickets).  This deposit is refundable only in circumstances deemed by the Expedition Leader to be exceptional.
\par 
\par Please do not hesitate to contact me (as Expo Treasurer) or Aaron Curtis (as Expo Leader) with any queries.
\par 
\par Thanks,
\par 
\par }\pard \ql \li0\ri0\widctlpar\tqr\tx8306\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {Richard Mundy\tab r.c.mundy.03@cantab.net
\par Magdalene College\tab 07906 362313
\par }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {Cambridge
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\par 
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Please continue on a second page if the fields provided are insufficient.\sect }\sectd \linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl \pard\plain 
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\par The medical information submitted on this form will be seen only by Richard Mundy (r.c.mundy.03@cantab.net) and Serena Povia (}{\cs17\dbch\af28 \hich\af0\dbch\af28\loch\f0 sp422@cam.ac.uk}{
).  We will disclose this information to the insurers, but it will not be seen by anyon
e else unless there is a risk of significant harm to yourself or others.  If you would prefer just to have Serena see this information, you are invited to arrange to send the form directly to her.  Serena is arranging the trip\rquote s insurance.
\par 
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\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
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\cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard 
\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Date of birth:\cell 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {
Do you already have appropriate medical/rescue insurance?\cell 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Would you like possessions insurance?
\cell 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
\f0\fs24 \hich\af0\dbch\af28\loch\f0 Are you waiting for an operation, a non-routine hospital consultation, are you HIV positive?  }{\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0 Do you have a terminal prognosis from a doctor?}{\f0\fs24 \cell }\pard\plain 
\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
\b\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0 In the last 12 months:}{\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0 
 Have you been medicated for a blood disorder, psychiatric illness or any cancer? Have you received a transplant or dialysis? Have you been treated in hospital for any heart or\hich\af0\dbch\af28\loch\f0  breathing problem?\cell }\pard\plain 
\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
\b\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0 In the last 3 months:}{\f0\fs24\cf0 \hich\af0\dbch\af28\loch\f0  Were you admitted overnight to a hospital? Have you been to a specialist for a non-routine consultation? \cell }\pard\plain 
\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {
Please continue on a second page if the fields provided are insufficient\sect }\sectd \linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl \pard\plain 
\s1\qc \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0 \fs28\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {CUCC Expo 2007 \endash  Medical Details
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\par The medical information submitted on this form will be seen only by Richard Mundy (r.c.mundy.03@cantab.net) and Dr. Phil Underwood (phil@furbrain.org.uk).  The information will not be disclosed to anyone else unless there is a ris
k of significant harm to yourself or others.  If you would prefer just to have Phil see this information, you are invited to arrange to send the form directly to him.  Phil is our medic.
\par 
\par }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 
\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Full name:\cell 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard 
\ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {Date of birth:\cell 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
\f0\fs24 \hich\af0\dbch\af28\loch\f0 Do you have any medical conditions which may require medical attention
\par \hich\af0\dbch\af28\loch\f0 while on expo (e.g. diabetes, epilepsy, asthma)?}{\f0\fs24\cf0 \cell }\pard\plain \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
\f0\fs24 \hich\af0\dbch\af28\loch\f0 Are you on any medication? If yes, what medication?}{\f0\fs24\cf13 \cell }\pard\plain \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {

\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\pard\plain \s18\ql \li0\ri0\widctlpar\intbl
\tx916\tx1832\tx2748\tx3664\tx4580\tx5496\tx6412\tx7328\tx8244\tx9160\tx10076\tx10992\tx11908\tx12824\tx13740\tx14656\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs20\cf1\lang2057\langfe1033\loch\af28\hich\af28\dbch\af28\cgrid\langnp2057\langfenp1033 {
\f0\fs24 \hich\af0\dbch\af28\loch\f0 Do you have any allergies?}{\f0\fs24\cf13 \cell }\pard\plain \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par 
\par \cell }\pard \ql \li0\ri0\widctlpar\intbl\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\trowd \trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth8568\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3888 \cellx3780\clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680 \cellx8460\row }\pard \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {
Please continue on a second page if the fields provided are insufficient.
\par }}