1. Are you currently incapable of independently​ carry out two or more of basic activities of daily living such as getting up, walking, toileting, dressing or feeding?  

2. Are you currently a resident of a long-term care facility, nursing home, nursing facility or assisted living resident?

3. Are you in need of an organ transplant, on a waiting list  for an organ transplant or the recipient of an organ transplant

(excluding corneal transplant)?

4.Within the past 30 days, have you been admitted to a hospital for more than 48 hours (excluding pregnancy)?

5.Within the past 60 days, have you been advised by a physician:

• Of any abnormal diagnostic tests?

• To have surgery or a diagnostic test or special test of any type?

• To consult with a physician, medical institution or specialist that has not yet been completed?

6. Have you ever been diagnosed with a life threatening, critical or terminal condition for which a physician has estimated that you have 24 months or less to live?

7. Have you ever had, been told you have, or been treated for Acquired Immunodeficiency Syndrome (AIDS), or have you ever tested positive for Immunodeficiency?

8. Within the past 10 years, have you had, been told you have, been treated for, or been advised to have investigation, that has not yet been completed for:

• Metastatic cancer, or more than occurrence of cancer (excluding  basal cell carcinoma)?

• Cystic Fibrosis or a chronic respiratory condition (excluding sleep apnea) which required the continuing administration of oxygen?

• Dementia, Alhzeimer"s Muscular Dystrophy, Huntington"s Chorea or Amyotrophhic Lateral Sclerosis (ALS)?

• Congestive heart failure or cardiomyopathy?

9 Have you ever had, been treated for, or been diagnosed prior to age 40 with: chronic kidney disease , stroke, (CVA), transient ischemic attack (TIA), aneurysm, coronary artery disease, heart bypass surgery, angioplasty, stent insertion, angina or heart attack?

10. Within the past 12 months, have you used narcotics or barbiturates (except as prescribed by a physician), heroin, psychoactive drugs, cocaine, crack or other similar agents, or been a resident of a drug or alcohol treatment facility?

11.Within the past 12 months, have you been convicted of, or awaiting sentencing for, incarcerated, for or on probation for a criminal offence, or do you currently have any criminal charges pending?

12. Is your weight greater than that indicated for your height in the following:

Height                         Weight

4’8” — 4’10”                230 lbs  

4’11” — 5’1”                247 lbs 

5’2” — 5’4”                  273 lbs

5’5” — 5’7”                  300 lbs

5’8” — 5’10”                328 lbs

5’11” — 6’1”                358 lbs

6’2” — 6’4”                  389 lbs

6’5” — 6’7”                  420 lbs