Your Name (Required)

Your Age (Required)

Your e-mail (Required)

Your Phone (Required)

weight (Required)

height(Required)

Do you smoke? (Required)
YesNo

If yes, since when?(Required)

How many cigarettes for day?

Do you drink?
YesNo

If yes, How often?

Do you take any kind of medication, drugs or have you in the past? if yes, which ones?

Do you/have you suffer of any kind of disease? if yes explain

¿have you been submitted to any surgery before? / if yes explain

Any kind of trauma?

Do you have kids? / If yes, how many?

Do you have Family in our country (Dominican Republic)?