Medical Conditions - Please check the box if you have had any of the following: 18.0
	Anemia Blood Disease Excessive Bleeding Heart Condition Heart Disease Heart Murmur Hemophilia High Blood Pressure High Cholesterol Irregular Heart Beat Low Blood Pressure Pacemaker Rheumatic Fever Scarlet Fever Sickle Cell Anemia Stroke If so, when? Nutrition Deficiency Stomach Problems Stomach Ulcers	AIDS Arthritis Cancer: List type Chemotherapy - If so, when? Radiation - If so, when? Chicken Pox Diphtheria HIV Positive Leukemia Measles Mumps Polio Rheumatism Sexually Trans Disease Sore Throat (Frequent) Tetanus Tumors	Diabetes Thyroid Problem ADD or ADHD Asperger's Syndrome Autism Cerebral Palsy Dizzy Spells or Fainting Epilepsy or Seizures Head Injury Intellectual Disability Nervous Disorder Psychiatric Disorder Hepatitis A B C Jaundice Liver Disease Kidney Disease or Trouble Pregnant Due Date	Asthma Bronchitis Mouth Breathing Respiratory Problems Sinus Trouble Snoring Tuberculosis Use Inhaler Whooping Cough Artificial Joints Orthopedic Problem Scoliosis Spina Bifida Hearing Impairment Vision Impairment
	List any other condition you may have