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Medical History

Are you under a physician's care now?

Have you ever been hospitalized or have a major operation 

Have you ever had a serious head or neck injury ?

Are you taking any medications, pills, or drugs 

Do you take, or have taken, Phen-Fen or Redux? 

Are you on a special diet? 

Do you use tobacco? 

Do you use control substance?   

women only 

Please Select

Are you allergic to any of the following? 

Please Select

Do you have, or have had, any of the following:

Please Select
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