Questionnaire Text

Questionnaire form view entire document:  text  image

3. Day, month, year of birth _ _/_ _/_ _ _ _


3. Date of birth

_ _ Day
_ _ Month
Year

[] 1870
[] 1880
[] 1890
[] 1900
[] 1910
[] 1920
[] 1930
[] 1940
[] 1950
[] 1960
[] 1970
[] 1980

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9

Questionnaire instructions view entire document:  text  image

3. Day, month and year of birth: _____