Do you smoke or use any other form of tobacco? Yes No

Do you totally abstain from alcohol? Yes No

Have you been denied health coverage in the past 12 months?

Yes No

Have you been treated by a physician in the past 12 months? (excluding voluntary annual check ups, pap smears, minor colds & flu, etc.)

Yes No

Have you been hospitalized in the past five years? (excluding pregnancy) Yes No

Are you currently taking any prescription medications? (excluding voluntary prescriptions such as Viagra, diet pills, vitamins, mineral supplements, calcuim, or oral contraceptive) Yes No

Are you receiving any ongoing medical treatments? (excluding regular pap smears, voluntary check ups, etc.) Yes No

Do you wish to retain an existing Doctor? Yes No

Have you been a resident in the United States for at least 11 of the last 12 months? Yes No

Have you been diagnosed with any of the following:
Asthma Diabetes High Blood Pressure Cancer

HIV/AIDS
Heart Attack/Stroke Other Major Illness