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General Health

Have you ever been diagnosed, treated or prescribed medicine for:

High blood pressure


Liver disease or disorder, pancreatic, kidney, or lung disease

Severe Asthma

Do you have a mental or nervous disorder including:

  • Dementia or Parkinsons
  • Down Syndrome
  • Severe Mental Disability
  • Major depression, bipolar or schizophrenia

Have you received an organ transplant or had an amputation due to disease?

Do you have a disability that prevents you from working 30 hours a week, or receive disability benefits such as SSDI?

Does your family have a history of cardiovascular diseases such as heart attack, stroke, or angina?


Driving issues in the last 3 years:

  • Had an alcohol or drug related infraction
  • 2 or more vehicle accidents
  • 3 or more driving violations
  • Had your license suspended or revoked

Have you been convicted of a misdemeanor or felony in the last 5 years, or on probation/parole in the past 6 months?