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Participant Information

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Dietary Information

(if none, enter N/A)

Medical Information

(if none, enter N/A)
(if none, enter N/A)
(if none, enter N/A)
(if none, enter N/A)
(if none, enter N/A)
(if none, enter N/A)

Pre-existing Medical Conditions

Please answer Yes/No to the following. In the past 3 years, have you experienced:

Electronic Signature of Participant