Personal Information

Please complete your questionnaire and all consent forms completely.

How did you hear about us?

Medical History

If not applicable, please type N/A in each box.

Do You...

Drink Alcohol?
Smoke Tobacco Products? *
Use Recreational Drugs? *

Do you have any of the following conditions?

Congestive heart failure *
Heart block *
Unexplained significant swelling of the feet and legs *
Kidney failure or dialysis *
High calcium levels in blood *
Sarcoidosis *
Hemachromatosis (iron overload) *
Leber's Disease (hereditary optic nerve atrophy) *
History of fainting during blood draws or IVs *
Abnormal heart rhythms *
Uncontrolled high blood pressure *
Recurrent kidney stones *
Hyperparathyroidism *
Sickle Cell disease *
G6PD deficiency *
Hypersensitivity to cobalt *

Does your family have a history of the following conditions?

Hemachromatosis (iron overload) *
Sickle Cell disease *
G6PD deficiency *
Other conditions *
Are you a male or female? *