US, CAN, UK etc.

Please ADD country code

If available, please write the name of the medication, the daily dose (e.g., 100mg - 2x1), and the duration of use. If not, you can write "none".

If you received it, please write down the type and dosage of treatment.

Male patients may leave this blank without marking it.

Add 'w' to the beginning of the number if you are female, and 'm' if you are male. Example: w-2 or m-4

If there are any things that raise your suspicions, please explain briefly.