| 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 | None | ||||||||||
| Are you any taking prescription medications? | Yes | ||||||||||
| Please list all of the prescription medicines you are taking |
| ||||||||||
| Have you been affected by a sexually transmitted infection/disease? | No |
