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The document is a Medical Marijuana Patient Intake Form from PDI Medical, LLC. It collects patient information, medical history, and details about the patient's health conditions and habits to assess eligibility for medical marijuana use. The form includes sections for personal data, family medical history, current medications, symptoms experienced, prior cannabis use, and consent for sharing medical records. It also outlines legal disclosures regarding the use of medical marijuana in Illinois and the associated risks.

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