1. Head/brain injuries or illnesses (e.g., concussion) |
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2. Seizures/epilepsy |
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3. Eye problems (except glasses or contacts) |
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4. Ear and/or hearing problems |
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5. Heart disease, heart attack, bypass, or other heart problems |
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6. Pacemaker, stents, implantable devices, or other heart procedures |
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7. High blood pressure |
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8. High cholesterol |
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9. Chronic (long-term) cough, shortness of breath, or other breathing problems |
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10. Lung disease (e.g., asthma) |
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11. Kidney problems, kidney stones, or pain/problems with urination |
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12. Stomach, liver, or digestive problems |
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13. Diabetes or blood sugar problems Insulin used |
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14. Diabetes or blood sugar problems Insulin used |
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15. Fainting or passing out |
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16. Anxiety, depression, nervousness, other mental health problems |
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17. Unexplained weight loss |
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18. Stroke, mini-stroke (TIA), paralysis, or weakness |
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19. Missing or limited use of arm, hand, finger, leg, foot, toe |
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20. Neck or back problems |
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21. Bone, muscle, joint, or nerve problems |
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22. Blood clots or bleeding problems |
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23. Cancer |
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24. Chronic (long-term) infection or other chronic diseases |
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25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring |
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26. Have you ever had a sleep test (e.g., sleep apnea)? |
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27. Have you ever spent a night in the hospital? |
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28. Have you ever had a broken bone? |
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29. Have you ever used or do you now use tobacco? |
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30. Do you currently drink alcohol? |
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31. Have you used an illegal substance within the past two years? |
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32. Have you ever failed a drug test or been dependent on an illegal substance? |
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