Name: Date of Birth: 12345678910111213141516171819202122232425262728293031JanFebMarAprMayJunJulAugSepOctNovDec20001999 19981997199619951994 1993 1992 1991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967 1966 196519641963196219611960 Weight (in kilograms): Height (in centimeters): Smoker?:Yes No (Diabetis, Cancer, Asthama) Any from them?:YesNoSexually?: ActiveInactive
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