Name and explain each medication and dose(Required) Please include over-the-counter medications as well.
Provide additional information about your hospitalization(s)(Required) Please be sure to indicate why and when.
Provide additional information about your operation(s)(Required) Please include the kind of surgery and when.
When did you quit?(Required) Please provide an estimate for when you quit smoking.
Smoking Duration(Required) For how many years did you smoke previously?
How many?(Required) How many cigarettes did you smoke per day?
When did you start?(Required) Please provide an estimate for when you started smoking.
How many?(Required) How many cigarettes do you smoke per day?
How many drinks?(Required) How many drinks do you consume per week?
Type of beverage?(Required) Please specify your preferred type of alcoholic beverage (wine, beer, spirits).
Who in your family experienced anemia?(Required) Please provide any context or details you can.
Who in your family experienced asthma?(Required) Please provide any context or details you can.
Who in your family experienced cancer?(Required) Please provide any context or details you can, including type of cancer.
Who in your family experienced degenerative bone or joint disease?(Required) Please provide any context or details you can.
Who in your family experienced diabetes?(Required) Please provide any context or details you can.
Who in your family experienced heart attack(s)?(Required) Please provide any context or details you can.
Who in your family experienced heart disease?(Required) Please provide any context or details you can.
Who in your family experienced heart operation(s)?(Required) Please provide any context or details you can.
Who in your family experienced high blood pressure?(Required) Please provide any context or details you can.
Who in your family experienced high cholesterol?(Required) Please provide any context or details you can.
Who in your family experienced stroke(s)?(Required) Please provide any context or details you can.
Who in your family experienced sudden death?(Required) Please provide any context or details you can.
Who in your family experienced thyroid disorder(s)?(Required) Please provide any context or details you can.