Please indicate if you have ever had (check all that apply):

During the past year have you experienced any of the following (check all that apply):

Have you ever had any of the following (check all that apply):

Select if any of your biological parents or grandparents had any of these conditions (check all that apply):

List all current medications, and how you take it:

Indicate the nature and date of any surgeries you have had:

Indicate other details which would be useful for your specialist in understanding your needs: