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Are you prone to any of the following ?
Are you allergic to any substances ? If yes, please specify
Are you currently on any medication? If yes, please list below :
How do you rate your diet ?
How is your sleep schedule ?
Do you currently smoke or use tobacco products ?
Describe your alcohol consumption
Do you exercise?
Do any of your blood relatives have any of the following conditions ?
Do any of your blood relatives have any other medical condition besides those already mentioned ? If yes, Please mention the condition :
Mark any of the following Cardiovascular/Hematologic conditions you have been diagnosed with in the past :
Mark any of the following Gastrointestinal conditions you have been diagnosed with in the past:
Mark any of the following neurological conditions you have been diagnosed with in the past:
Mark any of the following Urological conditions you have been diagnosed with in the past:
Mark any of the following ENT conditions you have been diagnosed with in the past :
Mark any of the following endocrinological conditions you have been diagnosed with in the past :
If you have been diagnosed with diabetes in the past, please specify the type :
Mark any of the following psychological conditions you have been diagnosed with in the past:
If you have been diagnosed with any other psychological condition, please specify the type :
Mark any of the following Respiratory conditions you have been diagnosed with in the past:
Mark any of the followingMusculoskeletal/Rheumatologic conditions you have been diagnosed with in the past:
Mention if you have been diagnosed with cancer in the past. If yes, specify the type:
Mention if any Other Medical Condition that you have been diagnosed with in the past :
Do you experience pain in any of the following areas ?
If yes, Please specify
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