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Patient Name: Do you have any of the following (please circle yes or no): High Blood PressureYesNoNumbnessYesNoHeadacheYesNoHeart ProblemsYesNoFatigueYesNoPacemakerYesNoNauseaYesNoCirculation ProblemsYesNoDizzinessYesNoDiabetesYesNoTinglingYesNoSeizuresYesNoSwellingYesNoHerniaYesNoHeat
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