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RemindMeDoc CheckUp Questionnaire
Find Out What You're Due For
* Indicates required question
Email
*
Record my email address with my response
Full Name
*
Your answer
Age(years)
*
Your answer
Biologic Sex at Birth
*
Choose
Male
Female
Height(inches)
*
Your answer
Weight(lbs)
Your answer
Smoking History
*
Never Smoker
Former smoker for less than 20 years
Former smoker for over 20 years & quit over 15 years ago
Former smoker for over 20 years & quit within the last 15 years
Active smoker
Submit
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