No Cardiovascular disease or cancer in either parent or
Siblings before age 60

No Cardiovascular or cancer death in either parent before age 60

No Cardiovascular or cancer death of more than one parent
Before age 60.

No cardiovascular death of more than one parent before age 60

No more than 2 moving violations in last 3 yrs. No DWI, DUI, reckless driving, license revocation or suspension in past 5 yrs

No more than 3 moving violations in last 3 years. No DWI, DUI, reckless driving, license revocation or suspension in past 3 years.

No more than 4 moving violations in last 3 years No DWI, DUI, reckless driving, license revocation or suspension in
Past 2 years.

Never used tobacco or nicotine based products

Currently uses tobacco or nicotine based product, choose one:

Cigarettes

Pipe

Chews

Nicorette Gum or Patch

Cigar # per mo:

Formerly used tobacco or nicotine based product

Blood pressure well controlled on medication at least
6 months

UL

Term