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Your Name (required)

Your Email (required)

Your Address

Your Phone (home and/or cell)

Full Birth Name

Public Name (the name you are currently using)

Additional Surnames

Nicknames and/or Abbreviations of Name (who they were given by and at what age)

Legal Name (how you sign documents, if different than above)

Adopted Name (aware of Birth Name before second given name)

Full Birth Date

Physical Symptoms (past, present, chronic)

Reason for your interest in Personal Research