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Patient and Caregiver Registration Form

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Select the Medical Condition (s) you or the patient have been diagnosed with: (Please select all that apply)

Allergy (e.g.hayfever, food allergy etc.)

Alzheimer's Disease

Anorexia

Attention Deficit Hyperactivity Disorder (ADHD)

Autoimmune Disease - Crohn's Disease

Autoimmune Disease - Lupus

Autoimmune Disease - Multiple Sclerosis

Autoimmune Disease - Psoriatic Artritis

Autoimmune Disease - Rheumatoid Arthritis

Autoimmune Disease - Ulcerative Colitis

Autoimmune Disease - Other (Please specify below)

Anxiety

Bladder Condition (e.g. OAB, Incontinence etc.)

Bladder Condition - Other

Blood Pressure - High

Blood Pressure - Low

Cancer - Breast Cancer

Cancer - Colon Cancer

Cancer - Lung Cancer

Cancer - Prostate Cancer

Cancer - Other (Please specify below)

Chronic Fatigue Syndrome / ME

Diabetes - Type 1

Diabetes - Type 2

Dementia

Depression

Erectile Dysfunction / Impotence

Eye Condition - Cataracts

Eye Condition - Long Sightedness

Eye Condition - Short-Sightedness / Myopia

Eye Condition - Other (Please specify below)

Fibromyalgia

Gastric Condition - Irritable Bowel Syndrome (IBS) / IBD

Gastric Condition - Other (Please specify below)

Haemophilia

Hepatitis A

Hepatitis B

Hepatitis C

High Cholesterol

HIV / AIDS

Hypothyroidism or Thyroid Disorder

Infertility

Insomnia

Lung Condition - Asthma

Lung Condition - Bronchitis

Lung Condition - COPD

Lung Condition - Emphysema

Lung Condition - Peripheral Vascular Disease

Lung Condition - Other (Please specify below)

Migraine

Muscle / Joint Condition - Ankylosing Spondylitis

Muscle / Joint Condition - Polymyalgia

Muscle / Joint Condition - Arthritis (don't know what type)

Muscle Joint Condition - Other (Please specify below)

Neuropathy

Obesity

Osteoporosis

Parkinson's Disease

Sexually Transmitted Infection

Skin Condition (e.g. Dermatitis, Eczema, Psoriasis etc.)

Other Conditions (not listed)

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