your full name: your birth date your age: your height: your weight: smoker or non smoker: Smoker Non-Smoker your gender: Male Female your state of residence: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY list medications: if so what are they for: known health issues:
