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Gender
Date of birth
Height
Weight
Smoker?
Applicant
M
F
/
/
Ft
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Spouse
--
M
F
/
/
Ft
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
0
1
2
3
4
5
6
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Children
--
M
F
/
/
Ft
0
1
2
3
4
5
6
7
In
0
1
2
3
4
5
6
7
8
9
10
11
Currently Insured?
Yes
No
Have conditions?
Yes
No
Please specify
Take medications?
Yes
No
Please specify
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