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Any Tobacco Use in the Past 12 Months?	Select None Cigarettes Cigars Pipe Chew Tobacco Nicotine Patch or Gum
Date of Birth	Select Month January February March April May June July August September October November December   Select Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Select Year 2010 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 1900
Gender	Male Female
Your Height	Feet 4 feet 5 feet 6 feet 7 feet   Inches 1 Inch 2 Inch 3 Inch 4 Inch 5 Inch 6 Inch 7 Inch 8 Inch 9 Inch 10 Inch 11 Inch
Your Weight
Check all that apply. Do you have a history of:	Diabetes?   Heart Attack?    Cancer? Date of last treatment:
Health Questions
Approximate Date Diagnosed with Diabetes	month & Year
Insulin dependent? If yes, Insulin used per day?	Yes   No
Is it controlled with Medication?	Yes   No If Yes, Specify Name of medication taken:
Is it Diet Controlled?	Yes   No
Last A1C Number
Any History of:
Heart Disease?	Yes   No
Stroke?	Yes   No    If Yes, date of last stroke: (month/Year)
Heart Attack?	Yes   No    If Yes, date of last heart attack: (month/Year)
Hypertension?	Yes   No
High Cholesterol?	Yes   No
Kidney Disease?	Yes   No
Kidney Dialysis?	Yes   No If Yes, date of last treatment: (month/Year)
Albumin or protein in urine?	Yes   No
Change in vision or retinopathy?	Yes   No
Numbness or neuropathy?	Yes   No
Skin Ulcers?	Yes   No
Have You Ever Been Declined for Insurance? If Yes, when?	Yes   No Select Month January February March April May June July August September October November December    Select Year 2010 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 1900
List all medications, dosage and frequency taken.
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