*Required Fields					Tobacco Use: Past 12 Months?
		Date of Birth Information
	Gender	Month	Day	Year
Applicant *	Select One Male Female	Select One January February March April May June July August September October November December
Spouse	--- Male Female	--- January February March April May June July August September October November December
Child #1	--- Male Female	--- January February March April May June July August September October November December
Child #2	--- Male Female	--- January February March April May June July August September October November December
Child #3	--- Male Female	--- January February March April May June July August September October November December
Child #4	--- Male Female	--- January February March April May June July August September October November December
Child #5	--- Male Female	--- January February March April May June July August September October November December