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Name :   Date of Birth :  
Year at KSU :
Address :  
Phone :  
Email :  
Current Height :   ft.     in.  
Current Weight :   lbs.  
Highest Weight :   lbs.  
Have you ever been diagnosed with :
High or Low Blood Pressure    
Heart or Blood Disease    
Type 1 or Type 2 Diabetes    
Asthma or other respiratory problems    
Kidney Disease    
Thyroid Problems    
Liver Problems    
Eating Disorder    
Depression or other psychological disorder    
Other medical problems:    

Do you have any current of past illness/injuries that prevent you from exercising?
Do you have any special dietary needs?
(e.g. food allergies, gluten-free, etc.)
Why are you interested in flashLITE?
(in less than 100 words)