Health Information

1.1 Heart attack, angina, chest pain, stroke, TIA, elevated blood pressure or cholesterol, murmur or other heart or blood vessel disease or disorder? *

1.2 Asthma or other respiratory disorder? *

1.3 Arthritis, MS, ALS, muscle or back disorder? *

1.4 Back pain, disc disease, rheumatism, gout, arthritis, paralysis, polio, fibromyalgia, or disorder, pain or stiffness of the muscles or bones including joints, back, neck and spine, or a hip, knee or other joint replacement, amputation, or any conditions causing crippling or limited motion or requiring adaptive devices? *

1.5 AIDS, HIV testing, any HIV-related disease, any blood or lymph gland disease or disorder? *

1.6 Any other physical, mental or nervous symptoms, disease, impairments, or disorders not listed on this page? *

1.7 Deafness, blindness, optic neuritis or other visual disturbance, or any other disorder of the eyes, ears, nose or throat including loss of speech? *

1.8 Dizziness, fainting, convulsions, headaches, epilepsy, any sleep disorder, memory loss or impairment or any disorder of the brain or nervous system? *

1.9 Autism? *

2.0 Wheelchair bound? *