Are you a smoker? | Non-smoker | ||||||||||
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Do you consume alcohol? | Weekly | ||||||||||
Do you exercise? | Sometimes | ||||||||||
Describe your diet | Tasty food | ||||||||||
Describe any allergies or reactions you have | None | ||||||||||
Are you any taking prescription medications? | Yes | ||||||||||
Please list all of the prescription medicines you are taking |
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Have you been affected by a sexually transmitted infection/disease? | No |