All personal information is Optional

Name
Address
City and State
Zip Code
Age Birth Year Birth Place
Race Sex

Education Level
Your Occupation
Spouse’s Occupation
Marital Status Married how many times
Children Yes No
Size of Family Please list children by age and sex
Pets
Medical Information
Blood Type Bone Marrow
Describe your Health
Are you aware of any Genetic or Hereditary Diseases
Do you take vitamins and mineral supplements Yes No How often
Do you consume at least 6 glasses of water a day Yes No
If not, how many glasses a day do you consume/drink
Do you exercise on a regular basis Yes No If not, how often
Do you crave sweets Yes No How often
Do you drink sodas, carbonated drinks Yes No How often
How often do you drink caffeine beverages
How often do you drink decaffeinated beverages
Do you drink alcohol beverages Yes No How often
Do you smoke cigarettes Yes No How many packs a day
Do you smoke marijuana Yes No How often
Do you use drugs, non-prescription Yes No How often
Do you use drugs, prescription Yes No How often
Environmental
Population of the Town or City you live in
Area
Altitude Level
Describe Weather in summer
Describe Weather in winter
Are Pollution Alerts
Are there any Chemical plants in or around your neighborhood
What type
Within how many miles
Are there any Electrical Power Plants, Substations or Power Lines in or around your neighborhood
Within how many miles
Notes