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  Health Questionnaire

  Do you suffer, or have suffered from any of the following?

  Yes   /   No
Arthritis    /   
Any Infection or Infectious Diseases    /   
Asthma    /   
Back Pain    /   
Diabetes    /   
Heart Palpitations/Chest Pain    /   
  Yes   /   No
Epilespy    /   
Been pregnant Recently    /   
Heart Condition    /   
Major Injuries    /   
High/Low Blood Pressure    /   

  Please, write if you have other health issues other than the above.


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