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General Health

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

High blood pressure


Any chronic liver, pancreatic, kidney, or lung disease

Any hospitalizations or medication changes in the last 12 months for Asthma

Do you have a mental or nervous disorder including:

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

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

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

Within the last 12 months, have you had, or been advised to have diagnostic testing, surgery, or been hospitalized, or have you been treated or diagnosed with any other disease, disorder, injury, or had surgery?

Within the last 30 days, have you been advised by a doctor to get medical care, which was not completed, as a result of fever, cough, shortness of breath or fatigue? (Non-HIV/AIDS)


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?