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| 1. |
What is your first and last name? |
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250 characters remaining
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| 2. |
What is your address? |
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| 3. |
Phone numbers and information. |
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| 4. |
What is your date of birth? |
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| 5. |
Where were you born? (City/State) |
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| 6. |
What is your height? |
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| 7. |
What is your weight (in pounds)? |
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| 8. |
Which answer best describes any recent weight changes you may have experienced. |
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Please Explain
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| 9. |
What is your highest earned Degree? (specify degrees) |
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Please Explain
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| 10. |
What is your race? |
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| 11. |
Are you adopted? |
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| 12. |
Have you ever been convicted of a crime? (if yes, please explain) |
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Please Explain
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| 13. |
Do you have any allergies to medicines, food, pollen, etc.? (if yes, provide substance and reaction caused) |
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Please Explain
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| 14. |
Do you use tobacco products? (if yes, please complete the following table) |
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| 15. |
Have you ever taken anti-malarial drugs or had malaria? |
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Please Explain
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| 16. |
Have you had any major radiation exposure or X-ray exposure? |
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Please Explain
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| 17. |
Have you had any sexually transmitted diseases within the past year? |
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| 18. |
Are there any known genetic diseases or conditions that run in your family? (if yes, what are they) |
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Please Explain
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| 19. |
How many sexual partners have you had in the past 6 months? |
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| 20. |
Did you spend a total time of 6 months or more associated with a military base in any of the following countries: Belgium, Netherlands, Germany, Spain, Portugal, Turkey, Italy, or Greece? (if yes, need dates and locations) |
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Please Explain
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| 21. |
Between 1980 and 1996, did you spend time that adds up to more than 3 months or more in the United Kingdom (England, Scotland, Wales)? |
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Please Explain
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