First Name (*):
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Gender:	Male Female
Do You smoke? Yes No
Do you currently or have you ever had a blood pressure problem? Yes No
Have you been examined by a healthcare provider within the last 12 months? Yes No
Have you ever been told you have any sort of heart condition? Yes No
I agree not to take this medicine if i am currently or if I ever have been treated for any heart problems Yes No
Please describe any special medical condition, injuries or chronic diseases.
Please list any medications you are currently taking if any:

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