Are you now or have you ever been treated for any of the following: (check all that apply)

Hypertension (High Blood Pressure)
Heart Disease (CHD, CAD, MI, A fib)
Lung/Respiratory Disease
Ear/Sinus Problems
Muscular/Skeletal Conditions
Psychiatric/Psychologic Issues
Behavioral Problems (ADD, ADHD, etc)
Fainting Spells
Thyroid Disease
Kidney Disease
Blood Clotting Conditions
Sleep Disorders
Abdominal/Digestive Disorders

If you checked any of the above, please elaborate here on your conditions and treatment:

By typing my full name in this box, I am effectively signing and agreeing to the following: I am only seeking this antibiotic preparedness pack in order to be prepared for a situation where conventional medical care may not be available. I further agree that if such a "grid-down" situation does not exist, and I have a condition that may require antibiotics, that I will seek evaluation and treatment at my local medical facility.

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