Dr. Diet Patient Form
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  3. (valid email required)
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  14. Are you currently under a doctor's care for any reason?
  17. Have you had any surgery within the past two years?
  20. Are you allergic to any medications?
  23. Are you currently taking any medications?
  26. Are you pregnant or nursing?
  29. Do you or any family members have a history of:
  30. Rheumatic Fever
  32. Kidney Stones
  34. Convalsions
  36. Pleurisy
  38. Ulcer
  40. Stroke
  42. Urinary Disorder
  44. High Blood Pressure
  46. Asthma
  48. Heart Attack
  50. Arthritis
  52. Gout
  54. Anemia
  56. Colitis
  58. Epilepsy
  60. Cancer
  62. Diabetes
  64. Tubeerculosis
  66. Rheumatism
  68. Hepatitis
  70. Mental Illness
  72. Tumors
  74. Endometriosis
 

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