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* Full Name

* What is your date of birth?

Month	Day	Year

* What is your gender?

Male

Female

Trans

* What is your marital status?

* Have you ever been in the armed forces?

* Do you have a history of abuse or violence?

Yes

No

* Are you aware of any emotional triggers? Please describe them.

* How do you identify? (bottom, sub, switch, pig, sissy, etc.)

* List medical conditions, history, surgeries and all medications currently taking.

* How did you come across my website?