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Gender
 
Male
 
Female
 
 
 
Age:
 
<20
 
20-45
 
45-70
 
>70
 
 
 
Smokes cigarettes:
 
Yes
 
No
 
 
 
Exercise Habits(days per week)
 
1-2
 
3-5
 
>5
 
Not regular
 
 
 
Which alcoholic beverage do you drink?
 
Beer
 
Malt Beverage
 
Mixed Drinks
 
Shots
 
Wine

 
 
 
How often do you drink alcohol?
 
 
 
How often do you get drunk (where you know you cant drive legally)?
 
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