* First Name
* Last Name
-U.S. Virgin Islands-
When was DES taken?
What condition was this medication prescribed to treat?
What was the name of the medication taken that contained DES?
Who has been affected by DES use (i.e. son/daughter/grandchildren)?
Have any of the following been diagnosed? (Please check all that apply.)Clear Cell Adenocarcinoma MicrophallusInfertilityEpididymal CystGenital DefectsBreast Cancer
Please further describe side effects:
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