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YES NO Emphysema or Chronic Obstructive Pulmonary Disease (COPD) (circle if applicable) YES NO Thyroid Problems (Hypothyroid or Hyperthyroid) YES NO Diabetes. YES NO Chemical Dependency (i.e. alcoholism, addiction) YES NO Stomach ulcers. YES NO Multiple Sclerosis or Guillain-Barre Syndrome. YES NO Rheumatoid Arthritis/ Ankylosing Spondylitis ................
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