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Eck one number per line) County IRRATIONAL JUDGMENT CONFUSED IMPULSIVE HALLUCINATIVE DELUSIONAL COMPLIANT AGITATED FEARFUL WITHDRAWN AGGRESSIVE REFUSES ACTIVITIES Zip Documentation of MR/DD Included: Yes No Gainful Employment: Is or Has Been Married: Level of Retardation (IQ Score): Yes No Yes No PRIOR LIVING ARRANGEMENT: Own Home Mental Hospital (IMD) ICF/MR-Private ICF/MR Relative s Home Hospital SNF Asst. Living ICF/MR-Public.
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