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Your Gender:	Male Female
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Please list any current medical conditions:	None
Please list any prescription, herbal or over the counter medications you are currently taking:	I do not take any other medications
Please list any prescription, herbal or over the counter medications you plan to take while on this program:	I do not plan to take any other medications
Please list all allergies (including medications):	I do not have any allergies
Is there anything else in your medical history you deem relevant:	None
Do you have any of the following conditions: Leukemia, Multiple Myeloma, Sickle Cell Disease, Peptic Ulcers, or Retinitis pigmentosa?	No Yes
Do you take any form of nitroglycerine?	No Yes
We require a valid prescription for your order. Please fax or email it to /	I understand that if a prescription has not been provided, my order will not be processed

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