HISTORY: Please write down if you have or have had any of the following:
Arthritis, Asthma, Cancer (if yes, what kind and when ___________________)
Coronary Artery Disease, Diabetes, Eczema, Heart Attack, Heart Disease,
Hemophilia, High Blood Pressure, HIV/AIDS, Hypothyroid, Hyperthyroid,
Hepatitis, Kidney Disease, Liver Disease, Fatty Liver, Lyme Disease, Mononucleosis,
Rheumatic Fever, Scarlet Fever, Seizures/Epilepsy, STD, Stroke, Tuberculosis,
OTHER:
WRITE ANSWERS BELOW-