First Name Middle Initial Last Name Email Address Phone (###-###-####) PLEASE CHECK THE BOX IF YOU HAVE BEEN DIAGNOSED WITH THE CONDITION. HIGH OR LOW BLOOD PRESURE VASCULAR DISEASE VLUNG DISEASE LUNG DISEASE ASTHMA OR COPD TB BRAIN TUMOR MIGRAINE OR HEADACHE LOSS OF HEARING VISUAL IMPAIRMENTS EPILEPSY/SEIZURES THYROID DIEASE HYPOTHYROID DIEASE HYPERTHYROID DIEASE GALLBLADDER DISEASE GASTRIC ULCER GASTRIC REFLUX PROSTATE ENLARGEMENT BLOOD IN STOOL OR URINE ARTHRITIS BACK PAIN NECK PAIN HEPATITIS A, B, C LIVER DISEASE HIV/AIDS KIDNEY DISEASE KIDNEY STONES DIABETES ANXIETY DEPRESSION MENTAL HEALTH ISSUESADDICTION ISSUES SUCH AS : OPIOID DEPENCENCY ALCOHOL DEPENDENCY SUBSTANCE ABUSE ANY OTHER HEALTH ISSUES
