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    Date of Birth

    Have you ever had any of the following?

    AllergiesLoss of HearingAsthmaLiver DiseaseElevated Liver Enzyme TestHeartAttackHeart MurmurPositive Stress TestHeart Valve AbnormalityAnginaHearth FailureHigh CholesterolHigh Blood PressureArthritis/RheumatismEpilepsyStrokeDiabetesThyroid troubleCancer (including skin cancer)

    Do you or have you recently had any of the following?

    Shortness of BreathChest tightnessWheezingHerniaFainting SpellsRecurrent dizzinessFrequent headachesTremorsLoss of coordinationDifficulty ConcentratingNumbness/tingling extremitiesPalpitations (irregular heartbeat)Pain or discomfort in chestHigh cholesterolSwelling of feetLeg pain while walkingPainful varicose veins

    Do you or have you recently had any of the following?

    Back trouble/painNeck trouble/painJoint injury/pain/swellingCarpal tunnel syndromeChronic fatigueUndesired/unexplained weight lossDifficulty sleepingLow blood sugar

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