• 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)

  • Drinks

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

  • Moving violations

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

  • Work full-time

  • Have you ever been diagnosed or treated for:

  • Diabetes?
  • Multiple sclerosis?
  • Cancer?

  • Have you ever been diagnosed or treated for:

  • Kidney disease?
  • Heart disease?
  • Liver disease?

  • Have you ever been diagnosed or treated for:

  • High blood pressure?
  • Is your blood pressure currently in the normal range?
  • High cholesterol?
  • Is your cholesterol currently in the normal range?
  • Depression or anxiety?
  • Have you ever been admitted to a hospital for depression or anxiety?
  • Have you had more than two episodes of depression or anxiety that required treatment in the past two years?
  • Has your depression or anxiety ever caused you to become unemployed?

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

  • Stroke?
  • Heart disease?
  • Cancer?

  • 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.

  • *
  • Should be Empty: