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Blood Type Please select A+ A- B+ B- O+ O- AB+ AB-

Disabilities Physical disability Intellectual or learning disability Psychiatric disability Visual impairments Hearing impairments Neurological disability

Allergies Eggs Milk Peanuts Tree nuts Fish Shellfish Wheat Soy Pollen Rubber Chicken Cat Dog Mold Cockroach Latex Trees / Grass Insect Sting

Allergy Others

Medical Histories Alcoholism Alzheimer`s Amblyopia Anaphylaxis Anemia Aneurysm Arrhythmia Arthritis Asthma Biliary Tract Disease Bipolar Disorder Blindness Cancer Cataplexy Cataracts Chronic Pain Cirrhosis Collapsed Lung Color Blindness Congestive Heart Failure COPD Coronary Artery Disease Crohn`s Disease Cryptococcus Cystic Fibrosis Cytomegalovirus Degenerative Arthritis Depression Dermatitis Diabetes Ectopic Pregnancy Endometriosis Epilepsy Erectile Dysfunction Gallstones Glaucoma Glomerulonephritis Gout Headaches Hearing Impairment Hepatitis A Hepatitis B Hepatitis C HIV Hypertension Hyperthyroidism Hypothyroidism Immune Deficiency Infections (chronic) Infertility Insomnia Ischemic Bowel Disease Kidney Stones Lupus Lyme Disease Macular Degeneration MAI Menopause Multiple Sclerosis Narcolepsy Nephrotic Syndrome Ocular Misalignment Osteoporosis Ovarian Cysts Pancreatitis Parkinson`s Disease Peripheral Neuropathy Pleural Effusion Prostate Enlarged Prostatitis (chronic) Psoriasis Pulmonary Embolism Pulmonary Fibrosis Reflux Esophagitis Renal Failure Retinal Detachment Rheumatoid Arthritis Sickle Cell Anemia Sinusitis (chronic) Sleep Apnea Somnambulism Spina Bifida Stroke Thalassemia Tinnitus Toxoplasmosis Tuberculosis Ulcers

Medical History Others

Family Medical Histories Alcoholism Alzheimer`s Amblyopia Anaphylaxis Anemia Aneurysm Arrhythmia Arthritis Asthma Biliary Tract Disease Bipolar Disorder Blindness Cancer Cataplexy Cataracts Chronic Pain Cirrhosis Collapsed Lung Color Blindness Congestive Heart Failure COPD Coronary Artery Disease Crohn`s Disease Cryptococcus Cystic Fibrosis Cytomegalovirus Degenerative Arthritis Depression Dermatitis Diabetes Ectopic Pregnancy Endometriosis Epilepsy Erectile Dysfunction Gallstones Glaucoma Glomerulonephritis Gout Headaches Hearing Impairment Hepatitis A Hepatitis B Hepatitis C HIV Hypertension Hyperthyroidism Hypothyroidism Immune Deficiency Infections (chronic) Infertility Insomnia Ischemic Bowel Disease Kidney Stones Lupus Lyme Disease Macular Degeneration MAI Menopause Multiple Sclerosis Narcolepsy Nephrotic Syndrome Ocular Misalignment Osteoporosis Ovarian Cysts Pancreatitis Parkinson`s Disease Peripheral Neuropathy Pleural Effusion Prostate Enlarged Prostatitis (chronic) Psoriasis Pulmonary Embolism Pulmonary Fibrosis Reflux Esophagitis Renal Failure Retinal Detachment Rheumatoid Arthritis Sickle Cell Anemia Sinusitis (chronic) Sleep Apnea Somnambulism Spina Bifida Stroke Thalassemia Tinnitus Toxoplasmosis Tuberculosis Ulcers

Family History Others

Smoker

Alcohol Drinker

Takes Illicit Drugs

Immunizations Adenovirus Anthrax Cholera Diphtheria Hepatitis A Hepatitis B Haemophilus influenzae type b (Hib) Human Papillomavirus (HPV) Seasonal Influenza (Flu) Japanese Encephalitis Measles Meningococcal Mumps Pertussis Pneumococcal Polio Rabies Rotavirus Rubella Shingles Smallpox Tetanus Tuberculosis Typhoid Fever Varicella Yellow Fever

Immunization Others

Civil Status Please select Single Married Divorced Separated Widowed

Nationality

Religion Please select Prefer not to say Alliance of Bible Christian Communities Baptist Born Again Christian Buddhism Catholic Christian Church of God Evangelical Iglesia ni Cristo Jehovahs Witness Life Renewal Christian Ministry Lutheran Methodist Aglipay LDS-Mormons Islam Pentecostal Protestant Seventh Day Adventist UCCP Unknown Wesleyan Others

Highest Education Please select Prefer not to say Post Baccalaureate College Graduate College Undergraduate Vocational Highschool Graduate Highschool Undergraduate Elementary Graduate Elementary Undergraduate No Formal Education/No Schooling Others

Occupation