[PRACTICE NAME]
Acid Reflux Y N Fibromyalgia Y N Neuropathy Y N Anemia Y N Gout Y N Open Sores Y N Arthritis Y N Heart Attack Y N Pneumonia Y N Asthma Y N Heart Disease/Failure Y N Polio Y N Back Trouble Y N Hepatitis Y N Rheumatic Fever Y N Bladder Infections Y N HIV+/AIDS Y N Sickle Cell Disease Y N Abnormal Bleeding Y N High Blood Pressure Y N Skin Disorder ... ................
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