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Genetic Background
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Education
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Education (Other)
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Occupation/Job Title
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Personal Medical History
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Irritable Bowel Syndrome
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Crohn's
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Ulcerative colitis
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Peptic Ulcer disease
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GERD (reflux)
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Celiac disease
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Personal Medical History cont.
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Heart Attack
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Congestive Heart Failure (CHF)
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Stroke
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Elevated cholesterol
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Arrhythmia (irregular heart rate)
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Hypertension (high blood pressure)
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Angina (Chest Pain)
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Mitral valve prolapse
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Ankle swelling or General Edema
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Personal Medical History cont.
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Type 1 Diabetes
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Type 2 Diabetes
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Hypoglycemia
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Metabolic syndrome (pre-diabetes)
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Hypothyrioidism (low thyroid)
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Hypothyroidsim (overactive thyroid)
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Polycystic Ovarian Syndrome
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Weight gain
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Weight loss
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Personal Medical History cont.
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Kidney stones
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Kidney Failure
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Interstitial cystitis
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Dialysis
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Urinary Tract Infection
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Personal Medical History cont.
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Osteoarthritis
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Fibromyalgia
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Chronic pain
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Liver Disease
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Personal Medical History cont.
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Chronic Fatigue Syndrome
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Autoimmune disease
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Rheumatoid arthritis
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Lupus SLE
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Immune deficiency disease
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Severe infectious disease
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Poor Immune function
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Food allergies
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Environmental allergies
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Multiple chemical sensitivities
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Latex allergy
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Sickle Cell
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Personal Medical History cont.
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Asthma
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Chronic sinusitis
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Bronchitis
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Emphysema
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Pneumonia
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Tuberculosis
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Lung Disease
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Sleep Apnea
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Pulmonary Hypertension
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Personal Medical History cont.
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Eczema
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Psoriasis
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Acne
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Melanoma
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Skin Cancer
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Personal Medical History cont.
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Lung cancer
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Breast cancer
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Colon cancer
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Ovarian cancer
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Prostate cancer
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Skin cancer
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Personal Medical History cont.
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Depression
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Anxiety
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Bipolar disorder
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Schizophrenia
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Headaches
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Migraines
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ADD/ADHD
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Autism
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Memory problems
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Dementia/Alzheimer's
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Parkinson's disease
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Multiple Sclerosis
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Seizures
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Please list any other significant Medical History or Surgical Procedure
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Women's History
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Are you or could you potentially be, pregnant?
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Medication History
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Please list all current prescription or over the counter medication
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