Have you been hospitalizzed in the last 10 years? |
|
Are you a private pilot, or do you participate in any of the following: Scuba diving, hang-gliding, auto or motorcycle racing, bungee jumping, mountain climbing? |
|
Any moving violations in last 3 years? |
|
DUI/DWI in the last 5 years? |
|
Recommended for treatment or treated for alcohol/substance abuse |
|
History of cancer, other than basil cell carcinoma |
|
Details of foreign travel in past 12 months and next 12 months. |
|