Yuku User Name:

Email Address:

Gender: Male Female

Date of Birth: or age, if preferred

Resident Country:

Name of Condition: (ET, PT, etc)

Date Formally Diagnosed:

Symptoms:

Current Medication:

Any Side Effects?: If no, please state "none"

Past Medication:

Reason for change/cessation:

Any other illnesses or medical problems?

Any medication taken for other medical problems:

Any Allergies? if no, please state "none"

Blood Group:

Cholesterol Level: (count or low/normal/high)

JAK2 Gene? Positive Negative Don't Know - Select From List - (You will only know this if you have had a specific test for this mutation)

Please list any family history of blood disorders, heart attack, or stroke

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