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Patient Name: ___ Patient Phone: ___Age: ___DOB: ___Patient Email: ___(please select one program) Fit RX (Basic medical conditions. Please check condition) Hypertension Type 2 Diabetes Weight Loss

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Age-related disabilities may include vision and hearing impairments, reduced mobility, cognitive decline, and chronic health conditions.

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Individuals who are experiencing age-related disabilities may be required to file for disability benefits.

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The purpose of age-related disabilities may is to provide support and assistance to individuals who are experiencing limitations due to aging.

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Information such as medical records, doctor's statements, and details of the disability may need to be reported on age-related disabilities forms.

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