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 ISSUES

    ADDICTION ISSUES SUCH AS :

    OPIOID DEPENCENCY
    ALCOHOL DEPENDENCY
    SUBSTANCE ABUSE
    ANY OTHER HEALTH ISSUES