Apt. / Ste.
We need this information calculate your body mass index (BMI).
Date of Birth
Do you have any of the following health conditions?
A suppressed or compromised immune system (for example, frequent severe infections or a condition that prevents the body from fighting infections and diseases) Asthma Bleeding disorder Cancer (other than prostate cancer that has not spread, and fully treated non-melanoma skin cancer or cervical cancer) Chronic liver disease (including cirrhosis) Chronic obstructive pulmonary disease (COPD) Diabetes (including type 1, type 2, or gestational) Guillain-Barré syndrome (a condition in which the body’s immune system attacks the nerves, causing problems such as numbness, weakness, and pain) Any other condition that results in damage to the protective covering (myelin sheath) that surrounds nerves in your brain, eyes, and spine (e.g. multiple sclerosis, optic neuritis [inflammation of the nerve to the eyes], transverse myelitis [inflammation of the spinal cord]) Heart disease High blood pressure Obesity None of the above I’m not sure
If smoker, please tell us the brand of cigarettes and amount you smoke per day