Please fill out the information below. This information will help your physician decide on the best treatment for you. It is important that you are as truthful and complete as possible as this information will be used to determine the safety of different options of treatment. If you are missing some information, such as the names and dosages of all medications you are currently taking, please come back and fill out the information after you have gathered all the details.

These answers to questions might contain Protected Health Information data (restricted access by CareGLP team)