Have you ever been diagnosed with a developmental disability? | |
Have you had any serious illness, significant operation or hospitialization within the past 5 years?: | |
Have you had joint replacement surgery (such as: knee, hip, etc) within the past 5 years?: | |
Are you taking any medication(s) including non-prescription, homeopathic or or natural remedies including diet pills? If so, please list: | |
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Do you have any of the following diseases or problems? |
High blood pressure, arteriosclerosis (high cholesterol) | |
Damaged heart valves, artificial valves or heart murmur | |
Rheumatic Heart Disease | |
Heart trouble, angina, stroke, heart attack, or any other heart conditions | |
Chest pain upon exertion | |
Shortness of breath after mild exercise | |
Do your ankles swell | |
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Allergies | |
Asthma or hay fever | |
Diabetes Type I or II | |
Frequent of recurring mouth sores | |
Stomach ulcers or hyperacidity | |
Kidney trouble | |
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Cancer | |
Respitatory problems, emphysema, bronchitis, COPD etc | |
Arthritis or panful, swollen joints including jaw joint (TMJ) | |
Persistent cough or cough that produces blood | |
Epilepsy or neurological disorder | |
Any disease, drug or transplant operation that has depressed your immune system | |
Sexually transmitted disease(s) | |
Sinus Trouble | |
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Fainting spells or seizures | |
Hepatitis, jaundice or liver disease | |
Thyroid disease (hypo/hyper) | |
Tuberculosis | |
Low Blood Pressure | |
Persistent swollen neck glands | |
Have you had abnormal bleeding? | |
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Have you ever required a blood transfusion? | |
Do you have any blood disorder such as anemia? | |
Have you ever had treatment for a tumor or growth? | |
Do you have a history of sleep apnea? Do you currently use a CPAP machine? | |
Are you currently taking or have you taken these medication(s) in the past: Bisphosphonate therapy such as Fosamax, Boniva, Zometa, Aclasta, Reclast | |