Please create and enter a unique 8-12 character long ID code. This is used instead of a name to ensure that your medical information is anonymous and protected. Make sure to write it down so you can relay it to me later.
[Just like any password, it can be letters and/or numbers, like "cycle982" for example. Be sure to make it unique, so avoid generic phrases like '12345678' or 'Volkswagen'.]
What is your date of birth?
Please enter as Month/Day/Year, for example "03/15/1975"
What are your top 3 health concerns, in order of importance?
Click all of the conditions that apply to you:
[Mark all that apply, or SKIP if you don't have any on this list]