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Gender |
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Please indicate your preferred contact number |
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Medical History |
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Please indicate which side is being affected |
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Have you ever been diagnosed as having or have suffered from (Please check conditions that apply to you) |
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Do you drink alcoholic beverages? |
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Do you use any tobacco products? |
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Do you consume caffeine? |
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Do you exercise? |
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What percentage of the date do you normally spend: |
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Insurance Information |
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Policy Holder |
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