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    MEDICAL HISTORY (SELECT APPLICABLE CONDITION BELOW)

    High Blood PressureHeart ConditionKidneyHigh CholesterolConstipationThyroidGall BladderDiabetesHysterectomyLiver

    PLEASE SPECIFY IF YOU ARE:

    Pregnant: YesNo     Breastfeeding: YesNo     Vegetarian: YesNo

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