Ft In Lbs

Yes No
Yes No
Are you a full-time student? Yes No
Pre-existing conditions? Yes No
  • aneurysm
  • cancer
  • depression
  • diabetes
  • drug/alcohol
  • emphysema
  • heart disease
  • high blood pressure
  • kidney disease
  • MS
  • paralysis
  • pregnancy
  • stroke

ex: 555-123-3928

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