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Marital StatusSingleMarriedDivorcedWidowed
Do any children 18 or under reside in your household?
[radio* children-under18 use_label_element default:2 "Yes" "No"]
Child
Date of Birth
Gender
Child 1
MaleFemale
Child 2
Child 3
Child 4
Child 5
Are You?
HomeownerRegistered VoterComputer Owner
Pets
DogCatOther
Are you a smoker?
[radio* smoker use_label_element default:2 "Yes" "No"]
Do You Drink?
BeerWineLiquor / Mixed Drinks
Do You Have?
AllergiesAsthmaDiabetesMigrainesHigh Blood PressureHigh Cholesterol
Do you wear Contact Lenses?
[radio* contact-lenses use_label_element default:2 "Yes" "No"]
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