Contact Information
First Name
Last Name
Email
Telephone
What state do you live in?
Alabama
Alaska
Arizona
Arkansas
California
Carolina del Norte
Carolina del Sur
Colorado
Connecticut
Dakota del Norte
Dakota del Sur
Delaware
Florida
Georgia
Hawái
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Luisiana
Maine
Maryland
Massachusetts
Míchigan
Minnesota
Misisipi
Misuri
Montana
Nebraska
Nevada
Nueva Jersey
Nueva York
Nuevo Hampshire
Nuevo México
Ohio
Oklahoma
Oregón
Pensilvania
Rhode Island
Tennessee
Texas
Utah
Vermont
Virginia
Virginia Occidental
Washington
Wisconsin
Wyoming
What is your assigned gender at birth?
Male
Female
Other
What is your height?
Feet
Select feet
3
4
5
6
7
Inches
Select inches
0
1
2
3
4
5
6
7
8
9
10
11
How much do you weigh?
Lbs
Do you have any of the following conditions? ?
Select all that apply
High cholesterol
Fatty liver disease
High blood pressure
Pre-diabetes
Type 2 Diabetes
HbA1c above 5.7
None of the above
What is your date of birth?
Month
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
Year
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
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1929
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1937
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1951
1952
1953
1954
1955
1956
1957
1958
1959
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1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Day
Day
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What state do you live in?
Alabama
Alaska
Arizona
Arkansas
California
Carolina del Norte
Carolina del Sur
Colorado
Connecticut
Dakota del Norte
Dakota del Sur
Delaware
Florida
Georgia
Hawái
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Luisiana
Maine
Maryland
Massachusetts
Míchigan
Minnesota
Misisipi
Misuri
Montana
Nebraska
Nevada
Nueva Jersey
Nueva York
Nuevo Hampshire
Nuevo México
Ohio
Oklahoma
Oregón
Pensilvania
Rhode Island
Tennessee
Texas
Utah
Vermont
Virginia
Virginia Occidental
Washington
Wisconsin
Wyoming
What is your assigned gender at birth?
Male
Female
Other
What is your height?
Feet
Select feet
3
4
5
6
7
Inches
Select inches
0
1
2
3
4
5
6
7
8
9
10
11
How much do you weigh?
Lbs
Do you have any of the following conditions? ?
Select all that apply
High cholesterol
Fatty liver disease
High blood pressure
Pre-diabetes
Type 2 Diabetes
HbA1c above 5.7
None of the above
What is your date of birth?
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Send
