Name:
Date of Birth:
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JanFebMarAprMayJunJulAugSepOctNovDec
20001999 19981997199619951994 1993 1992 1991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967 1966 196519641963196219611960
Weight (in kilograms):
Height (in centimeters):
Smoker?:Yes No
(Diabetis, Cancer, Asthama) Any from them?:
YesNo
Sexually?: ActiveInactive