Study for sedative usersPersonal information First name * Last name * Gender * Male Female Date of birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 Smoking habits * Smoker Non-smoker Body Mass Index Imperial (pi) Metric (m) Height ' Height (inches) " Height m Height (cm) cm Weight kg Your BMI : Join us Preferred language * French English Phone * eg. 555 444-3333 Ext. Optional E-mail Postal code/Zip code * eg. H0H 0H0
