Have you used any form of tobacco in the last 12 months?
Have you been treated for any of the following?
Cancer, High Blood Pressure, Diabetes, Asthma, Immune
System Disorders, Depression/Anxiety, Heart Disease,
Drug/Alcohol Abuse, Epilepsy, or similar
Have you been convicted in reckless driving or driving under
influence of alcohol or drugs in the last 5 years?