*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
What is your smoking status?
How many years have you (or did you) smoke?
Are you exposed to passive (secondhand) smoke?
Do you consume alcohol?
Please answer yes or no if you or your partner have had any of the following: IV drug use, more than one sexual partner, unprotected sexual contact, contact with contaminated injection equipment, multiple blood transfusions, HIV or Hepatitis B.
Do you feel safe at home?
In the past year, have you been hit, punched, kicked or slapped by anyone?
Do you have any surgical history?
Past Medical History
Do you have any medical history problems?
Have you ever had sex?
Did you begin having sex before the age of 18?
Are you currently sexually active?
Are you planning a pregnancy this year?
Family Medical History
Do you have a family history of illnesses?