What is your history of tobacco/nicotine usage?

Never UsedCurrent userQuit within the last yearLast use over 1 year agoLast use over 2 years agoLast use over 3 years agoLast use over 5 years ago   

Has there been any occurrences of Coronary Artery Disease, heart disease, or any cardiac related condition of either natural parent or sibling prior to the age of 60?

Yes No   

Has there been any deaths from Coronary Artery Disease, of any natural parent prior to age 60?

NoYes, oneYes, Both   

Has there been any occurrences of Internal Cancer or Melanoma of either natural parent or sibling prior to the age of 60?

Yes No   

Has there been any deaths from Internal Cancer or Melanoma of any natural parent prior to age 60?

NoYes, OneYes, Both   

Have you ever been treated for hypertension (high blood pressure)?

Yes No   

What is your most current blood pressure reading?

I don't know140/85 or less145/90 or less150/90 or lessOver 150/90   

Have you ever been treated for cholesterol?

Yes No   

What is your most recent Total Cholesterol reading?

I don't know220 or less221-250250-280281-300Over 300   

What is your most current Cholesterol/HDL Ratio?

I don't know5.0 or under5.1-6.06.1-7.07.1-8.0Over 8.0   

Have you ever been diagnosed or treated for:

Alcohol/drug abuse	Cancer
Cadiovascular/Heart Disease	Stroke
Diabetes	Chronic Obstructive Pulmonary Disease
Hepatitis C	Kidney Disease
Liver Disease	Multiple Sclerosis

   

Do you have any of the following medical impairments?

Arthritis	Asthma
Crohn's Disease	Elevated Liver Function Tests
Epilepsy	Anxiety
Chronic Fatigue Syndrome	Gastric/Peptic Ulcers
Sleep Apnea

   

Have you received treatment for Depression within the last 2 years?

Yes No   

Have your received any vehicle driving violations (moving violations) in the past 3 years?

No, NoneYes, 1 violationYes, 2 violationsYes, 3 violationsYes, 4 or more violations   

Have you had any DWI, DUI, reckless driving, license revocation or supsenions in the last 5 years?

Yes No   

Are you a U.S. Citizen?

Yes No