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Great! What is your gender?

What is your birth date?

What is your height?

What is your weight?

Have you ever been diagnosed with the following:(check any that apply)

Do you use tobacco?

Do you have relatives with heart disease or cancer?

Do you have a hazardous hobby or occupation?

What is your marital status?

What is your work status?

Do you have any children?

Are any of the applicants expecting a child?

What is your full name?

What is your email address?

What is your phone number?

Male
Female
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Less Than 4ftTaller Than 8 Feet
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Less Than 50 lbsMore Than 500 lbs
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None Of These
Heart Problem
Asthma
Blood Pressure
Depression or Anxiety
Cancer
Stroke
Diabetes
Cholesterol
AIDS/HIV
Alcohol or Substance Abuse
Other Major Illness
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Yes
No
Yes
No
Yes
No
Married
Unmarried
Employed
Government
Housewife/Husband
Retired
Student Living w/ Parents
Stud. Not Living w/ Parents
Unemployed
Military
None
One
Two
Three
Four
Five
Six
More Than Six
Yes
No
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