Personal Health & Family History Of Propos |
|
|
Ever been on medication for Blood Pressure? |
|
Ever been on medication for High Cholesterol? |
|
Ever had a history of Alcoho or Drug abuse? |
|
Do you Fly, other than as a fare paying passenger? |
|
Ever been charged with DUI? |
|
Had more than 3 moving violations in last 3 years? |
|
Involved in a Hazardous occupation or Avocations? |
|
Any incidents, of your Parents or Siblings, prior to age 60 Having: Cancer; Stroke, Heart Attack or Heart Disease or Diabetes?
(Indicate number, type and ages(s) of diagnosis of each.)
|
|