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 Health Plans:  
 Date of Birth:  Height:
 Gender:     Weight: lbs
 Have you used any form of tobacco in the last 12 months?
 Are you currently insured or have been insured for the past 30 days?
 Is anyone in the family self-employed?
 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
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