Basic Information

What is your date of birth?*
Do you smoke, or have you recently quit smoking?*
Do you have any medical conditions?*
Are you allergic to any medication or do you have any allergies?*
Are you taking any medication? This includes non-prescription, over-the-counter medicines as well as herbal remedies.*
Have you recently stopped taking any medication?*
Is there a history of any illness that runs within your family?*
Do you have any liver or kidney problems?*
Have you had any heart problems, such as angina (chest pain) or a heart attack?*
Have you ever had a stroke or 'mini stroke'?*
Have you ever had any major surgery?*
What is your height / weight -> BMI*