Please answer all questions. If you do not know the answer, or do not understand the question, insert a question mark in the space.
Your weight:
Estimate the amount of alcohol you drink regularly:
Answers all questions. If you do not know the answer or do not understand the question, insert a question mark.Have you ever had any of the following? If so, indicate when. LEAVE NO BLANKS!!!
Have any of your blood relatives had the following?