Name *

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Mobile Phone *

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Home Address *

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Personal Medical History *

High blood pressure

Heart bypass

High cholesterol

Heart Disease (other)

Heart attack

Angina or other chest pain

Stroke or TIA

Blood clot and/or a pulmonary emboli

Arrhythmia

Pacemaker

Defibrillator

Anemia

Asthma

Emphysema

COPD

Hepatitis

HIV/AIDS

Lupus or other auto immune disease

Fibromyalgia

Trouble passing urine or take Flomax or Avodart

Chronic liver disease (fatty liver or cirrhosis)

Diabetes (Type 1)

Diabetes (Type 2)

Thyroid disease

Arthritis

Depression

Anxiety

ADD/ADHD

Cancer

Other

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