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    First name
    Last name
    Year of Birth
    Gender
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    City
    Postal Code
    Email
    Phone
    Do you have any medical conditions?
    YesNo
    Do you have Diabetes Mellitus Type 2?
    YesNo
    Do you have Cardiovascular Disease (CVD) - Heart or Vessels Disease?
    YesNo
    Do you have Hypertension (High Blood Pressure)?
    Did you have Cerebrovascular Accident (CVA) - Brain Stroke or Hemorrhage?
    YesNo
    Do you have Migraines?
    YesNo
    Do you have Gout?
    YesNo
    Do you have Arthritis?
    YesNo
    Do you have Fibromyalgia?
    YesNo
    Do you have Chronic Pain?
    YesNo
    Do you have Kidney Disease?
    YesNo
    Do you have Thyroid Disease?
    YesNo
    Do you have Anemia?
    YesNo
    Do you have a history of alcohol abuse?
    YesNo
    Do you have Obesity?
    YesNo
    Do you have Male Sexual Health Problems?
    YesNo
    Do you have Depression?
    YesNo
    Do you have Allergies or Asthma?
    YesNo
    If your medical condition is not in this list, please provide it below.
    Are you currently taking any medication?
    YesNo
    Do you have any history of smoking?
    YesNo
    Would you like to participate as a healthy volunteer?
    YesNo
    How did you hear about us?

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    Can we contact you in the future about studies that may pertain to you?
    YesNo