Dialadoctor Global – questionnaire

Your first name *

Your middle name

Your last name *

Your sex *

Your date of birth *

Your e-mail *

Your phone number *

Your weight, KG *

Your height, CM *

Your address: street, apartment, postal code, city, country *

Your lifestyle type *

Your blood type *

Your Rhesus *

Your national identification number (for FSMP) *

Do you use any pharmaceutical drugs at present? *

Have you had any surgeries in your lifetime? *

Additional information (if you want to add anything, please add it here)