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If you currently smoke cigarettes, how many packs daily?*
I used to smoke, but quit?
Other Tobacco Products; Check all that apply
I smoke cigars
I smoke a pipe
I chew tobacco
I chew nicotine gum
I am on 'The Patch'
Do you have any pre-existing medical conditions?
If "Yes", please explain?
Has any of parent sibling had cardiovascular disease or cancer?
If yes, please explain including age of onset, diagnosis, and death (if applicable)
Ever been treated for any of the following? (Check all that apply)
AIDS/HIV
Alcohol or Drugs
Alzheimer's Disease
Asthma
Cancer
Pulmonary Disease
Cholesterol
Diabetes
Depression
Heart Disease
Hypertension
Kidney Disease
Liver Disease
Mental Illness
Stroke
Ulcers
Vascular Disease
Other
If you checked any of the above, please explain date of onset or beginning of treatment, diagnosis, and current status
Please describe your occupation
Are you a private pilot or student pilot*
If yes, please explain type of rating, type of aircraft, total number of hours of experience, and number of hours flown per year (IFR, VFR, single-engine, multi-engine, etc.)*
Do you engage in scuba diving, sky diving, rock climbing, motorized racing, or any other hazardous avocation or occupation?*
If yes, please explain*
Have you been convicted of drunk drining in the past 7 years?*
Has your drivers license been suspended or revoked in the past 7 years?*
Been convicted of 2 or more moving violations in the past 3 years?*
Ever been convicted of, or are now awaiting trial for a felony?*
In the past 5 years, have you filed for bankruptcy?*
Are you a United States Citizen?*
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