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Health Plans:
Individual/Family Health Insurance
Medicaid
Dental Coverage
Medicare (age 64+)
Date of Birth:
-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
Height:
Ft
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Gender:
-
M
F
Marital Status:
-Select-
Single
Married
Separated
Divorced
Widowed
Weight:
Have you used any form of tobacco in the last 12 months?
Yes
No
Do you currently have health insurance?
Yes
No
Are you pregnant?
Yes
No
Do you take prescription medication?
Yes
No
Do you have any major health conditions?
Yes
No
Check any of the following that have been diagnosed (in the past 10 years):
AIDS/HIV
Depression
Mental Illness
Alcohol/ Drug Abuse
Diabetes
Pulmonary Disease
Alzheimer's Disease
Heart Disease
Stroke
Asthma
High Blood Pressure
Ulcer
Cancer
Kidney Disease
Vascular Disease
High Cholesterol
Liver Disease
Other
First Name:
Last Name:
Zip Code:
Address:
City:
State:
Day Phone:
Evening Phone:
Email:
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