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Medical History and Present Medical Condition Questionnaire
In order for you to gain the most benefit from this program, we encourage you to answer all the following questions. If you are uncomfortable with answering a particular question, feel free to leave it blank. Please explain all YES answers at the end of this questionnaire.
Personal Medical History
Have you ever had any of the following conditions?
1. Allergies *
2. Loss of hearing *
3. Asthma *
4. Kidney disease *
5. Prostatitis *
6. Colitis *
7. Hepatitis *
8. Liver disease *
9. Elevated liver enzyme test *
10. Pancreatitis *
11. Ulcer *
12. Heart attack *
13. Heart murmur *
14. Positive stress test *
15. Heart valve abnormality *
16. Angina *
17. Heart failure *
18. High cholesterol *
19. High blood pressure *
20. Arthritis/Rheumatism *
21. Loss of consciousness *
22. Epilepsy *
23. Convulsions/seizures *
24. Stroke *
25. Diabetes *
26. Thyroid trouble *
27. Anemia *
28. Eczema *
29. Cancer (including skin cancer) *
29. Cancer (including skin cancer) *
30. Sleep apnea *
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