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Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Height*
*
Weight*
Tobacco?*
- Yes
- No

What is your current marital status?*
Do you live in a nursing home or require adult daycare?*
- Yes
- No
Have you ever required adult care in the past?*
- Yes
- No
Do you work outside the home?*
- Yes
- No
Do you use any special assistance for walking, including the use of a cane, walker or wheelchair?*
- Yes
- No
Do you currently have long term care insurance?*
- Yes
- No
Do you have any major health conditions?*
- Yes
- No
Please select any health conditions that apply:*
- AIDS / HIV
- Alcohol / Drug Abuse
- Alzheimer's / Dementia
- Asthma
- Cancer
- Clinical Depression
- Diabetes
- Emphysema
- Epilepsy
- Heart Attack
- Heart Disease
- Hepatitis / Liver
- High Blood Pressure
- High Cholesterol
- Kidney Disease
- Mental Illness
- Multiple Sclerosis
- Pulmonary Disease
- Stroke
- Ulcers
- Vascular Disease
- Other / Not Listed

First Name*
Last Name*
Address*
City*
State*
Zip Code*
Day Phone*
Evening Phone*
Email*