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is this a new or recurring issue?NewReoccuring
Have you undergone any treatment for this condition?NoYes
Health Questions:
Are you pregnant?YesNoNot Applicable
Do you have sensitivity to light?YesNo
Do you have any history of: Heart DiseaseArthritisCancerDiabetesHemorrhagic DisordersDeep Vein ThrombosisOther
Are you on any medicationsNoYes
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