Check each tobacco product that you have EVER smoked or used:
Blood Pressure
Have you ever been treated for or taken medication for high blood pressure?
What is your systolic pressure?
What is your diastolic pressure?
Cholesterol
Have you ever been treated for or taken medication for high cholesterol?
What is your cholesterol level?
What is your HDL ratio?
Driving
Have you ever had a drivers license?
if you answer No, driving record is ignored
Have you ever been convicted of drunken driving (DUI/DWI)?
Have you ever been convicted of reckless driving?
Has your license ever been revoked or suspended?
Have you ever had more than one accident?
Please indicate the total number of moving violations/tickets (ie. not parking tickets) that you have received in each of the last time periods:
during the last 6 months:
during the last year, more than 6 months:
during the last 2 years, more than 1 year:
during the last 3 years, more than 2 years:
during the last 5 years, more than 3 years:
Family History
Family related deaths:
Please indicate the total number of family members (parents or siblings) who have died from cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:
Family related occurance of disease:
Not including those who died, please indicate the total number of family members (parents or siblings) who have contracted cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70: