General Health

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

High blood pressure

Diabetes

Any chronic liver, pancreatic, kidney, or lung disease

Have you ever been diagnosed with asthma?

Have you ever been treated for or diagnosed with lupus (SLE) or multiple sclerosis?

Have you ever been diagnosed with a mood or mental health disorder?

Have you ever 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?

Have you ever had, or been treated for, a stroke, heart attack, aneurysm, heart or circulatory disease?

Have you had, or been treated for, cancer in the last 7 years?

In the past 12 months, has any testing, treatment or procedure been recommended or scheduled but not yet completed, excluding routine testing?

Within the past 6 months, have you been hospitalized or have ongoing medical complications due to COVID?

Within the past 4 years have you abused alcohol or drugs or been recommended to receive any treatment, counseling or discontinue use of alcohol or drugs?

Offenses

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?