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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?
Do you wear a medical bracelet?
Do you have any allergies?
Do you take any medications?
Please select all that apply:
Do you give us permission to take pictures/videos for promotional/social media purposes?

Thanks for submitting!

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