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Please provide the exact address where you would like to receive your recommendation card.
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Medical
What is/are the main medical problem(s) which you currently have or have had in the past?*:
HIV/AIDS
Nausea
Fibromyalgia
Seizures
Arthritis
Muscle Spasm
Migraine Headaches
Anxiety
Chronic Pain
Glaucoma
Cancer
Trouble Sleeping
Loss of Appetite
Weight Loss
Other
Are you
RENEWING
your recommendation (Have you had a recommendation in the last 10 years)*:
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No
Yes
Do you currently use specific medications for your medical condition?:
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No
Yes
Tried it
Are you taking any prescription medications or herbs? *:
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No
Yes
Do you have any allergies to any medications? *:
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No
Yes
Have you ever had any surgeries or been hospitalized?:
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No
Yes
Do you exercise?:
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No
Yes
Do you smoke tobacco?:
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No
Yes
Do you drink alcohol?:
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No
Yes
Are there health/medical problems that occur frequently in your family?:
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No
Yes
Have you experienced or been diagnosed with any of the following *:
Depression
Bipolar Disorder
Schizophrenia
Suicidal thoughts
ADHD
None
Are you pregnant? *:
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No
Yes
Breastfeeding?:
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No
Yes
Do you have a primary care provider? *:
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No
Yes
When was the last time you saw your doctor/specialist about these complaints? (mm/dd/yyyy)
Medical Files
If available, you will have an ability to upload to your portal previous Recommendation or any other medical records as related to the medical condition(s) identified above.
I cannot provide the records because of:
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What is my CVV code?
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