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Get Durham Regional Hospital Psychiatry Form

Of caller: Phone: Fax Number: Date: Patient Name: Sex: DOB: / / Age: Race/Ethnicity: Presenting Problem: (note: if OD or ingestion of drugs/ETOH-please report blood levels and time obtained).

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  • dob
  • Ethnicity
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  • ingestion
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  • Incontinent
  • Opiates
  • referral
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  • OUTPATIENT
  • ALTERATION
  • seclusion
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