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Abnormal bleeding AIDS/HIV Positive Alzheimer's Disease Anemia Angina Are you on blood thinners Arthritis / rheumatism Artificial Heart Valve Artificial Joint Asthma Atrial fibrillation Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cigarette, pipe, or cigar smoking Cirulation problems Cortisone / steroids Cough, persistent or bloody Convulsions Dermal fillers Diabetes (type) Diarrhhea, persistent Digestive disorder Dizziness, fainting Do you drink alcoholic beverages? Do you use controlled substances ? Emphysema / bronchitis Epilepsy or Seizures Excessive urination Excessive Thirst Glaucoma Heart attack(date) Heart Pacemaker Hemophilia Heart defect Heart murmur / leaky valve Hepatitis(type) Herpes Hiatal hernia High or low blood pressure HIV / AIDS How much Hypoglycemia Joint replacement(knee, hip, etc) Kidney disease Leukemia / lymphomaLiver Liver Disease Lung Disease Mitral Valve Prolapse Neck / back problems Osteoporosis Pacemaker / defibrillator Pain in Jaw Joints Previous endocarditis Psychiatric Care Radiation therapy Rheumatic or scarler fever Shingles Shortness of breath Sinus infection Stroke(date) Sjorgren's syndrome Stomach ulcer / hyperacidity Swelling of feet or ankles Swollen glands - neck Thyroid disorder Tuberculosis Tumors or Growths Valve replacement Vision / hearing impaired Weight loss, unexplained