Required fields are marked with an asterisk *.
Have you ever had any of these medical illnesses? (Mark all that apply)
Have you been diagnosed or treated for blood clots? *
Have you ever had cancer? *
Have you ever had a problem with anesthesia? *
Have you ever had problems with wounds healing? *
Have you used any illicit drugs? *
Do you use tobacco products? *

Family History

Has your MOTHER had any serious/chronic illnesses? *
Has your FATHER had any serious/chronic illnesses?
Have your SIBLING(S) had any serious/chronic illnesses? *

Social History

Are you: *
Do you live: *
Employment *
How would you rate your quality of life now from 1 (worst) to 10 (best)? *


Are you allergic to any of the following? (Mark all that apply)

Current Medications

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