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1A. Health and Medical Issues

No, none of these ongoing health issues apply

Alcohol/Substance Abuse and Mental Health Alcohol usage Substance usage Bipolar Depression Manic Depressive Other Mental Health Arthritis Rhematoid Arthritis Systemic Lupis Cardiovascular Disease Angina Angioplasty Arrhythmia Atrial fibrillation Cardiovascular Cholesterol Coronary angioplasty Coronary bypass Coronary artery disease Heart Attack (Myocardial Infarction) Heart murmur Hypertension Hemochromatosis Hermochromatosis Irregular heart beats Myocardial infarction Pacemaker Pvc's palpitations Tachycardia Cancer Bladder Breast Cervical Colon Hodgkin's disease Melanoma Prostate Rectal Skin Other Cerebrovascular Disease Cerebral infarction Cerebrovascular disease Cerebral hemorrhage Cerebrovascular accident Stroke TIA Diabetes: Diabetes Type I Diabetes Type II Type Unknown

Gastrointestinal Chron's Disease Gastrointestinal disorder Ulcerative colitis Kidney Glomerulonephritis Kidney disease Kidney transplant Polycystic kidney disease Renal insufficiency Hepatitis Abnormal Liver functions Hepatitis Fatty liver Immune System Acquired Immune Deficiency (AIDS) AIDs Related Complex (ARC) HIV Infection Nervous System Epilepsy Multiple sclerosis Muscular dystrophy Parkinson's disease Neuromuscular disease Respiratory Asthma Chronic bronchitis Chronic obstructive pulmonary disease COPD Emphysema Respiratory Sleep Apnea

1B. Blood Pressure

Have you ever been diagnosed with or treated for high blood pressure? Choice... No HBP history over 2 years ago and since under control without medication BP has been stable with medication for at least two years HBP now but not treated Not certain but believe high or marginal

If you have been diagnosed or have a history of HBP, please specify: What is your blood pressure reading (if known)? Choice... Unknown 130 or less 135 or less 140 or less 145 or less 150 or less 154 or less more than 155 / Choice... Unknown below 85 85 or less 90 or less 95 or less 100 or less 101 or more

1C. Cholesterol

Have you ever been diagnosed with or treated for high Cholesterol? No Yes

If Yes, please specify: What is your cholesterol reading (if known)? Choice... Don't Know below 200 210 or less 220 or less 230 or less 240 or less 250 or less 260 or less 300 or less more than 300 What is your HDL/LDL Ratio (if known)? Choice... Don't Know 4.5 or less 5.0 or less 5.5 or less 6.0 or less 6.5 or less 7.0 or less 8.0 or less 8.5 or less more than 8.5

1D. Height & Weight

Height: Choice... 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" Weight: lbs.