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Have you used any form of tobacco in the last 12 months?

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Have you been treated for any of the following: Cancer, High Blood Pressure, Diabetes, Asthma, Immune System Disorders, Depression/Anxiety, Heart Disease, Drug/Alcohol Abuse, Epilepsy, or similar

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Have you been convicted in reckless driving or driving under the influence of alcohol or drugs in the last 5 years?

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