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Birth Date*
Month
01
02
03
04
05
06
07
08
09
10
11
12
Day
01
02
03
04
05
06
07
08
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11
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Year
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1962
1961
1960
1959
1958
Do you have any medical conditions?
Yes
No
Gender
Male
Female
Tobacco Use
No
Yes
Height
Height
3 Feet
4 Feet
5 Feet
6 Feet
Height
Inches
0 Inches
1 Inches
2 Inches
3 Inches
4 Inches
5 Inches
6 Inches
7 Inches
8 Inches
9 Inches
10 Inches
11 Inches
Weight
LBS
Weight
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
185
190
195
200
205
210
215
220
225
230
235
240
245
250
House hold size
Household Size:
1
2
3
4
5
6
7
8+
House hold income
50000
60000
70000
80000
90000
100000
110000
120000
130000
140000
150000
160000
170000
180000
190000
100000
210000
220000
230000
240000
250000
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