Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a U.S. Citizen?
*
Yes
No
Birth Date
*
-
Year
-
Month
Day
Date
Age
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Are you receiving any state financial aid (welfare) at this time?
*
Yes
No
Do you have any criminal history?
*
Yes
No
BMI
*
Do you smoke?
*
Yes
No
Do you drink?
*
Yes
No
Do you take any recreational drugs?
*
Yes
No
Do you have any STDs?
*
Yes
No
Do you have any history of chronic disease or cancer?
*
Yes
No
Please specify the type of chronic disease or cancer, when you were diagnosed, and any treatments you have undergone.
Has any member of your immediate family (parents, siblings, or children) been diagnosed with chronic diseases or cancer?
*
Yes
No
Please specify the type of chronic disease or cancer.
What is your highest level of education?
*
High School
Associate Degree
Some college courses completed
Bachelor's Degree
Master's Degree
Professional Degree
Is your schedule flexible to travel anywhere in the U.S. for 5-7 days? (travels expenses will be provided)
*
Yes
No
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