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Date of Birth:		Height:
Gender:	Male Female	Weight:	lbs
Have you used any form of tobacco in the last 12 months?			Yes No
Are you currently insured or have been insured for the past 30 days?			Yes No
Is anyone in the family self-employed?			Yes No
Has anyone in the family been treated for any of the following? Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar			Yes No

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