I failed.
I am not sure if it is really a mental hospital examination but it was certainly tricky.
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You can call me Thomas but this smatters of hoax. The number one tip-off is that it looks like it was created expressly to be distributed electronically, (perhaps as part of an e-mail urban legend promotional campaign) and does not appear to be a scan or some other reproduction of an actual document destined to be printed and given to a patient to complete.
Here in Canada where healthcare is free they tend to release patients as quickly as possible and tripping up someone’s release with an IQ-type quiz that has nothing to do with whether one poses a danger to himself or others is just silly.