Bleeding Disorder |
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Cancer |
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Diabetes |
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Glaucoma |
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Heart Disease |
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Hypertension |
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Kidney Disease |
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DRUG ALLERGIES
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Mental Illness |
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Osteoporosis |
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Seizures |
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Stroke |
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Thyroid Disease
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Allergies or Eczema
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Digestive Problems |
[ __ ] Memory
Loss |
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Arthritis |
[ __ ] Dizzy
Spells |
[ __ ] Sexually
TransmittedDisease |
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Asthma |
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Urinary Infections |
[ __ ] Shortness
of Breath |
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Blood in
Stool |
[ __ ] Glaucoma |
[ __ ] Skin
Disorder |
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Cancer |
[ __ ] Hepatitis |
[ __ ] Stroke |
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Cataracts |
[ __ ] Hemorroids |
[ __ ] TB/Lung
Disorder |
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Chest Pain/Pressure/Tightening |
[ __ ] Hypertension |
[ __ ] Ulcers |
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Depression |
[ __ ] Heart
Attack |
[ __ ] Other |
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Diabetes |
[ __ ] Headaches |
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Difficulty
Hearing |
[ __ ] Kidney
Disease |
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