General Medical History: Have you been diagnosed with any of the following? If yes, please note date(s) diagnosed.

General Surgical History: Please list any surgeries (including breast, gynecological, C-section, and colposcopy).

If NO or if you and your partner have only had sex with each other in your lifetime and you are in a healthy monogamous relationship and don't have any concerns related to STIs or bloodborne pathogens, you may skip this section.

5. How many sexual partners have you had in the last:

Please list family members related to you by blood who have been diagnosed with any type of cancer or other significant medical problems (e.g., parents, grandparents, children, siblings, etc.).

If YES, please complete the following 8 questions: