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Have you ever used tobacco or nicotine in any form? Yes No
Are you a U.S. Citizen? Yes No
Have you ever been diagnosed with or been treated for any blood pressure related disease? Yes No
Have you ever been diagnosed with or treated for high cholesterol levels? Yes No
In the last 10 years, has your drivers license been revoked or suspended or have you been convicted of, pled guilty to, or pled "no contest" to driving while impaired or intoxicated? Yes No
Do you participate in mountain or rock climbing, bungee jumping, sky diving, scuba diving or racing of powered air, water, or land vehicles? Yes No
Are you under treatment for any chronic condition such as, but not limited to, diabetes, mental illness, drug or alcohol use, stroke, cancer, heart, or circulatory disease? Yes No
   
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