Please select all that apply. If none of these apply, please check box that states "None of the above (Past history of medullary thyroid carcinoma, Active Medullary thyroid carcinoma, Family history of medullary thyroid carcinoma, Multiple Endocrine Neoplasia syndrome type 2) apply"
Other Medical Conditions
Please add any other medical conditions or health problems not listed above that you have or had in the past which is not listed above.
Allergies
Please add any allergy here if you have or had in the past. Check 'No Known Allergy' if you have or had not any in the past.
Surgeries
Please add all past surgeries.
Please check any medical condition or health problem that any of your family member currently have or had in the past.
