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Student Information
First name
Last name
Email
Code
Phone
Address
Name of doctor
Date of Birth
Do you suffer with
asthma
allergies
anemia
apathy
chest pain (not around heart)
chronic fatigue
coughing
deterioration of hearing
deterioration of vision
diabetes
emphysema & COPD
dry mouth
epilepsy
fear of sultry air
fear without reason
flashes before the eyes
headaches
high blood pressure
hypoglycemia
insomnia
irritability
kidney disease
lack of concentration
loss of feeling in the limbs
loss of smell
mental fatigue
migraine
panting
prone to coldss and flu
schizophrenia
short temper
shuddering in sleep
sudden physical exhaustion
trembling
varicose veins
weight gains
weight loss
Which medications do you take and dosage.
Medical history : trauma, accident or surgery.
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Thank you!
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