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This form is not a diagnostic instrument and is to be used solely within the context of your medical treatment with your physician or other health care provider. The maker and provider of this form disclaims any liability, loss, or risk incurred as a consequence, directly or indirectly, from the use and application of any of this material. WhatsMyM3™ V.03.06 Copyright © 2002-2012 by M3 Information™, The M-3 Checklist and WhatsMyM3.com are free for personal home use. For any other uses, including clinical., educational, non-profit, hospital research, or for-profit settings please contact mail@m-3information.com. No further reproduction or distribution, or reverse engineering is permitted without written permission from M3 Information. Patent Pending.