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Name
*
First
Last
Email
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Phone
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Have you been diagnosed with any of these medical conditions?
ALS
ALS
Alzheimer's
Arthritis
Autoimmune
Bronchial Asthma
Cardiovascular Disease
Crohn's Disease
Chronic Inflammation
Chronic Obtrusive Pulmonary Disease
Diabetes
Fibromyalgia/Chronic Pain
Hashimoto's
Heart Failure
Kidney Disease
Liver Disease
Lupus
Lyme Disease
Multiple Sclerosis
Neurological
Osteoarthritis
Parkinson's
Post COVID-19 Syndrome
Reflex Sympathetic Dystrophy
Rheumatoid Arthritis
Spinal Cord Injury
Stroke
Traumatic Brain Injury
Ulcerative Colitis
Other
(check all that apply)
Gender
Male
Female
Non-Binary
Health and Treatment Goals (optional)
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