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Health Information
*Gender
*Date of Birth
*Height
*Weight
Smoker
M
F
mm
Jan
Feb
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Apr
May
Jun
Jul
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Oct
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Dec
dd
1
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31
yyyy
1991
1990
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1986
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1982
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1978
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1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Ft
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Add Spouse?
Yes
No
Include Children?
0
1
2
3
4
5
6
Currently insured?
Yes
No
Current Insurance Carrier
Select ->
Other / My Company Is Not Listed
AETNA
Aflac
American Family Insurance
American Republic Insurance
Assurant
Blue Cross Blue Shield
Celtic Insurance
CIGNA
Farm Bureau Insurance
Golden Rule Insurance
Health Net
Health Plus of America
Humana
Kaiser Permanente
LifeWise Health Plan
Mega Life and Health Ins.
Metlife Insurance
Oxford Health Plans
PacifiCare
State Farm Insurance
Time Insurance
Tufts Health Plan
Unicare
United American Insurance
United HealthCare
Vista Health Plan
Is anyone pregnant?
Yes
No
Is anyone taking medications?
Yes
No
Please list which ones
Frequency
As Needed
1 Time Daily
2 Times Daily
3 Times Daily
4 Times Daily
Weekly
Pre-existing medical conditions?
Yes
No
Cancer
Stroke
Diabetes
Asthma
High Blood Pressure
Heart Disease
HIV/AIDS
Clinical Depression
Other Major Illness
Are you currently employed?
Yes
No
Are you self employed?
Yes
No
Contact Information
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*Address
*State
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