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Have you or any of your listed dependents been diagnosed or treated in the past five years by a medical or social practitioner for any of the following conditions No If yes please check condition s that apply and explain in chart below see below Condition Y Acquired Immune Disorder AIDS/HIV/Lupus Alcohol or Drug Dependency Diabetes or Sugar in Urine last 3 blood sugars and date Eye Ear Nose Throat Disorder Cataracts Blindness Deafness Alzheimer s Disease or Memory Loss Gall Stones Kidney...
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