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  Please narrate the intoxicants you are addicted to or you consume occasionally.
 
S.No : No of Intoxitant Duration of addiction Quantity consumed per day
1. :
2. :
3. :
4. :
5. :
6. :
7. :
       
  Please propose 3 occassions convenient for you to get your toxicity level assessed. Please fill your local time.
 
Date   Time  
Date   Time  
Date   Time  
             
     
   
 
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