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Questionnaire - Part II - Health History
Please select NOW if you're currently dealing with the condition, or PREVIOUSLY if you've experienced it in the past.
If neither apply, choose NEVER.
ADD or ADHD .....
AIDS .....
Alcoholism .....
Allergies .....
Anemia .....
Anxiety .....
Arthritis .....
Asthma .....
Bloating .....
Cancer ......
Chemical Sensitivities ......
Chronic Fatigue .....
Common Cold (Frequent) .....
Constipation .....
Diabetes I or II .....
Diarrhea .....
Dizziness .....
Drug Abuse .....
Environmental Sensitivities .....
Epilepsy .....
Epstein-Barr Virus .....
Excess Stress .....
Eyesight Problems .....
Fatigue .....
Gynecological Problems .....
Headaches .....
Hearing Problems .....
Heart Disease .....
Hepatitis A, B, or C .....
High Blood Pressure .....
HIV .....
Hyperglycemia .....
Hypoglycemia .....
Immune Disorders .....
Injuries .....
Low Blood Pressure .....
Male Health Problems .....
Memory Loss .....
Menopause Problems .....
Menstrual Irregularities .....
Numbness .....
Painful Joints .....
Rashes .....
Res[piratory Problems .....
Seizures .....
Shingles .....
Shortness of Breath .....
Sleep Problems .....
Sore Throat (Frequent) .....
Stiffness .....
Stomach Aches .....
Swelling .....
Tumors .....
Urinary Tract Infections .....
SURVEY PAGE 6
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