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Personal Information

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Emergency Contact

Medical History

Your perceived general health status
Do you have or have you ever had:*

1.  hospitalization for illness or injury

2. an allergic reaction to

3.  heart problems, or cardiac stent within the last six months

4.  history of infective endocarditis

5.  artificial heart valve, repaired heart defect (PFO)

6.  pacemaker or implantable defibrillator

7.  orthopedic implant (joint replacement)

8.  rheumatic or scarlet fever

9.  high or low blood pressure

10.  a stroke (taking blood thinners)

11.  anemia or other blood disorder

12.  prolonged bleeding due to a slight cut (INR>3.5)

13.  pneumonia, tuberculosis, emphysema, shortness of breath, sarcoidosis

14.  chronic ear infections

15.  asthma

16.  breathing or sleep problems (e.g., sleep apnea, snoring, sinus)

17.  kidney disease

18. jaundice 

19.  liver disease

20.  thyroid, parathyroid disease, or calcium deficiency

21.  hormone deficiency

22.  high cholesterol or taking statin drugs

23.  diabetes

24.  stomach or duodenal ulcer

25.  digestive or eating disorders (e.g., celiac disease, gastric reflux, bulimia, anorexia)25