Are you a smoker?Non-smoker
Do you consume alcohol?Weekly
Do you exercise?Sometimes
Describe your diet

Tasty food

Describe any allergies or reactions you have


Are you any taking prescription medications?Yes
Please list all of the prescription medicines you are taking
Name of Drug Start Date End Date Frequency Reason for Use
Advil now later 123 pain
Have you been affected by a sexually transmitted infection/disease?No
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