What is your:

Do you drink more than 21 drinks per week?

(one beer, one glass of wine or an ounce of liquor are all considered one drink)

Have you had more than one moving violation while driving in the past 12 months?

Do you currently work full-time (at least 30 hours per week)?

Have you ever been diagnosed or treated for:

Have you ever been diagnosed or treated for:

Have you ever been diagnosed or treated for:

Have 2 or more of your parents or siblings been diagnosed before the age of sixty with:

Are you currently getting paid to engage in any of the following occupations?

Check all that apply.

Do you, or are you planning to engage in any of the following activities?

Check all that apply.