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Gender
Male
Female
Birthdate
Current Age:
Height
4'10"
4'11"
5'
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
Weight
(lbs)
80-120
121-160
161-200
201-230
231-280
281-320
320+
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Household Size
1
2
3
4
5
6
7
8
Expected Household Income
Below $58,000
$58,000+
Qualifying Life Event
Got Married
Got Divorced
Loss of Coverage
Moved
Changed or Lost Job
Birth or Adoption
None of the Above
Any In The Last 10 Years?
Cancer
Heart Attack
Stroke
Diabetes
AIDS / HIV
Pulmonary Disease
None of the Above
Tobaco User?
Yes
No
Anyone Pregnant?
Yes
No
On Medicaid?
Yes
No
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