PM11
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[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-4] ........................
HAS NOT YET TAKEN/USED ................ XX
REF ................................... -7
DK .................................... -8
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IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
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IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
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OTHERWISE, GO TO PM10
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