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Please indicate your age:	21 - 29 years old 30 - 37 years old 38 - 44 years old 45 - 54 years old 55 - 64 years old 65 or over
Do you drink?	No socially medium heavy
Do you smoke?	No occasionally medium heavy
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I consider any discussion of money or service during our date to be in poor taste and to do so will result in the immediate termination of our appointment.