Medical History |
| Are you currently undergoing medical treatment |
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| Have you ever had, or do you currently have: |
| Heart Murmur |
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| Rheumatic Heart Disease |
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| Bleeding Disorders |
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| High or Low Blood Pressure |
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| Asthma |
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| Eczema |
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| Diabetes |
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| ADD or ADHD |
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| Epilepsy |
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| Tuberculosis |
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| Hepatitis |
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| HIV or AIDS |
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| Any Other Medical Conditions |
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| Allergies |
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| Any Other Allergies |
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| Any Medications, Supplements or Drugs |
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