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Medical Screening
Date of Birth
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Medical Screening
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I have been diagnosed with or told I have congestive heart failure (CHF)
I have been diagnosed with or told I have hemphilia
I have been diagnosed with or told I have kidney/renal failure or chronic kidney disease (CKD)
I am on dialysis
I have been diagnosed with or told I have pulmonary arterial hypertension (PAH)
I have history of uncontrolled bleeding
I have impairment preventing myself form making medical decision and/or consenting to my treatment
I currently have fluid build up in my feet, legs, or abdomen
I take medicine(s) for fluid retention (i.e. diuretic)
None of these
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