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Please fill out the following form in order to determine eligibility for services
❑ Angina
❑ Kidney disease
❑ HIV/AIDS
❑ Heart problems
❑ Kidney stones
❑ Congestive Heart Failure
❑ Cirrhosis of the Liver
❑ Edema
❑ Goiter
❑ Emphysema
❑ Hepatitis
❑ Cancer
❑ Stroke
❑ Stomach or peptic ulcer
❑ Leukemia
❑ Epilepsy (seizures)
❑ Rheumatic fever
❑ Psoriasis
❑ Cataracts
❑ Tuberculosis
❑ Diabetes
❑ Heart murmur
❑ Crohn’s disease
❑ High blood pressure
❑ Pneumonia
❑ Colitis
❑ High cholesterol
❑ Pulmonary embolism
❑ Anemia
❑ Hypothyroidism
❑ Asthma
❑ Jaundice