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Get Drug Usage Questionnaire 144e - Bmo.com

Dd/mm/yyyy Policy No.: (dd/mm/yyyy) 1. Are you now using or have you in the past used the following drugs? a) Opiates: heroin, , , , codeine, etc. Yes No b) Barbiturates: amytal, , , , pentonarbital, etc. Yes No c) Marijuana, hashish, cannabis, THC-Delta 9, etc. Yes No d) Amphetamines: , , methedrine, , etc. Yes No e) Cocaine, crack Yes No f) Hallucinogens: LSD, DMT, mescaline, peyote, psilo.

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  • DMT
  • psilocybin
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  • barbiturates
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  • Opiates
  • codeine
  • HASHISH
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