| DOB: |
| Your Program Title |
| ID # : 12345 |
| Attention: |
| Fax #: |
| Re: |
| Follow-Up Assessment Report |
| Patient's Call History |
| 6 |
| Yes |
| Yes |
| No |
| N/A |
| 06/14/00 |
| Screener |
| Unchanged |
| 6 |
| No |
| N/A |
| No |
| N/A |
| 06/16/00 |
| Follow-up |
| Much better |
| 4 |
| Yes |
| Yes |
| No |
| N/A |
| 06/16/00 |
| Follow-up |
| N/A = Not Asked |
| If you have any questions about fax, please call 608-827-2444. |