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Insurance Pre-Assessment Questionnaire
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
Your name?
2
What is your Date of Birth?
Select a date
3
What is your height in CMS?
Use digits only
4
What is your weight in KGS?
Use digits only
5
Are you a smoker?
Select one or more answers
Yes
No
6
If yes, please complete the following
Write in the blank fields below
Column
How many per day
Submit
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