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Personal Information

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Height Please Select Option < 5'5" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" Over 6'5"

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Ethnic Origin (Mother) Please Select Option American Indian or Alaska Native Asian Black or African American Caucasian East Indian Hispanic or Latino Middle Eastern or Arabic Mixed or Multi-Ethnic Native Hawaiian or Other Pacific Islander Other

Ethnic Origin (Father) Please Select Option American Indian or Alaska Native Asian Black or African American Caucasian East Indian Hispanic or Latino Middle Eastern or Arabic Mixed or Multi-Ethnic Native Hawaiian or Other Pacific Islander Other

Have your sexual partners in the last 5 years been Male Female Both

Have you been diagnosed with, or do you currently have, any serious medical problems (include hospitalizations, surgeries, or institutionalizations) Yes No

What was your diagnosis? At what age were you diagnosed? At birth 1-10 11-20 21-30 31-40 Over 40 Describe any treatment you received Remove this medical problem

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