Do you currently have or have ever had any problems with the following? For those where you have ticked 'yes', please explain in the test box below, and for surgeries/treatments, please provide date of last surgery/treatment.
Have you had or are you planning any of the following treatments? For those where you have ticked 'yes', please explain in the text box below.
Other medical conditions:
Please list any medications you are currently taking:
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