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Health Information

*Gender *Date of Birth *Height *Weight Smoker
Add Spouse?
Include Children?
Currently insured?
Yes No
Current Insurance Carrier
Is anyone pregnant?
Yes No
Is anyone taking medications?
Yes No
Please list which ones

Frequency
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?
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Are you self employed?
Yes No