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Past & Present Conditions

Name *

First Name

Last Name

Email Address *

In the past, have you ever had any of the following conditions? *

You may pick multiple conditions

Headaches

Neck Pain

Upper Back Pain

Mid Back Pain

Lower Back Pain

Shoulder Pain

Elbow/Upper Arm Pain

Wrist Pain

Hand Pain

Hip Pain

Upper Leg Pain

Knee Pain

Ankle/Foot Pain

Jaw Pain

Joint Pain/Stiffness

Arthritis

Rheumatoid Arthritis

Cancer

Tumor

Asthma

Chronic Sinusitis

High Blood Pressure

Heart Attack

Chest Pains

Stroke

Angina

Kidney Stones

Kidney Disorders

Bladder Infection

Painful Urination

Loss of Bladder Control

Prostate Problems

Abnormal Weight Gain/Loss

Loss of Appetite

Abdominal Pain

Ulcer

Hepatitis

Liver/Gall Bladder Disorder

General Fatigue

Muscular Incoorfination

Visual Disturbances

Dizziness

Diabetes

Excessive Thirst

Frequent Urination

Depression

Systemic Lupus

Epliepsy

Eczema/Rash

HIV/AIDS

Currently, do you have any of these conditions or symptoms? *