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What is your gender?
 
Male
 
Female
 
 
 
Do You Smoke?
 
Yes
 
No
 
 
 
How many years have you been smoking?
   
 
 
 
Which type do you smoke?
 
Argellah
 
Marllboro
 
Gtan
 
Vic Roy
 
Cartiar
 
GoldStar
 
Kilopetra
 
Mlokhia

 
 
 
Do you have health insurance
 
Yes
 
No
 
 
 
Do You Have Life Insurance?
 
Yes
 
No
 
 
 
Please rank the below according to priority (1 high priority / 5 least priority)
Work
Family
Health
Travel
Sleeping
 
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