1. Within the past 12 months, have you used by any means, a substance or product containing tobacco or nicotine (excluding cigars), or have you smoked (including electronic vaporizer or “vaping”) marijuana more than six times per week? *

Yes

2. Have you ever had, been told you have, or been treated for AIDS or have you ever tested positive for HIV? *

Yes

3. Are you currently being tested, waiting for results, or being monitored for any health condition that hasn't been diagnosed yet? Don't include: routine checkups, pregnancy, colds, flu, or minor injuries that don't require follow-up. *

Yes

Will your 66th birthday occur within the next 6 months from today? *

Yes

5. Have you ever had heart bypass surgery, angioplasty, or stent insertion, or have you been treated for, or been diagnosed with diabetes type 1 or 2, stroke (CVA) transient ischemic attack (TIA or mini stroke), aneurysm, coronary artery disease, angina, heart attack, congenital heart abnormality, heart failure, cardiomyopathy, heart valve disease, cerebrovascular disease or disorder of the heart or blood vessels? *

Yes

6. Have you ever had an abnormal cardiac, carotid or cerebrovascular test result without subsequent investigation establishing a normal result? *

Yes

7. Have you ever had, been treated for, or been diagnosed with cancer (excluding basal cell carcinoma), a benign or malignant brain tumor, aplastic anemia or a disease or disorder related directly or indirectly to aplastic anemia? *

Yes

8. Have you ever had an abnormal mammogram, PSA, colonoscopy, ultrasound, or PAP test result without subsequent investigation establishing a normal result? *

Yes

9. Have two or more members of your immediate family (father, mother, brothers, sisters) before the age of 60 ever had, been treated for, or been diagnosed with cancer, heart disease, stroke (CVA), transient ischemic attack (TIA or mini stroke) or aplastic anemia? *

Yes

10. Is your weight greater than indicated for your height in the following table? *

Yes

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