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Interstitial Cystitis and Vision

Section One: General Health History

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2. Have you ever smoked tobacco products on a daily basis for longer than one year? If yes, please include for how long:
3. Do you have any medical conditions involving your kidneys? If yes, please explain:
4. Do you have any medical conditions involving your liver? If yes, please explain:
5. Do you have any medical conditions involving your spleen? If yes, please explain:
7. Please indicate whether you report your weight in pounds (lbs) or kilograms (kg):
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