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Ll Name: Sex: M / F Address: City: Phone: Birthday: Doctor(s): Dr. Phone: Medical Conditions Check all that exist q No Medical Conditions q Angina q Asthma q Bleeding / Clotting Disorder q Cancer (Type) q COPD / Emphysema q Defibrillator q Dentures q Diabetes / Hypoglycemia q Fractures q Hearing Aids Allergies Check all that exist q No Known Allergies q q Latex q q Insect Stings q Aspirin q Heart Attack q Hepatitis q High Blood Pressure q HIV / AIDS q Kidney.

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