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Medical Screening Form

Date of Birth
Month
Day
Year
Do you presently or have you ever suffered from any of the following?
Do you smoke?
Yes
No
Do you drink?
Yes
No
Do you have a pacemaker?
Yes
No
Do you suffer from insomnia (disturbed sleep)?
Yes
No
Do you suffer from chronic migraines?
Yes
No
Do you have significant stress in your life?
Yes
No
(For women) Are you pregnant?
Yes
No
Are you sensitive to smoke, the burning of sage, cedar, Palo Santo, or spirit tobacco?
Yes
No
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Date
Month
Day
Year
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