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Have you used any tobacco, nicotine, or marijuana products in the last 5 years?

Yes No

Have you ever been diagnosed or treated for lung disease — COPD, emphysema, or asthma?

Yes No

Do you require the use of any oxygen equipment or inhalers?

Yes No

What type of oxygen use? (select all that apply)

Have you ever been diagnosed or treated for diabetes?

Yes No

Have you ever been diagnosed with cancer?

Yes No

Have you ever had kidney insufficiency, dialysis, cirrhosis, or hepatitis?

Yes No

Have you ever had a heart attack, bypass surgery, stent surgery, angina, pacemaker, defibrillator, stroke, seizure, or aneurysm?

Yes No

Have you ever been diagnosed with congestive heart failure?

Yes No

Which best describes it? (select all that apply)

Have you been diagnosed with lupus, multiple sclerosis, Parkinson's, or ALS (Lou Gehrig's)?

Yes No

Have you ever been diagnosed or treated for depression, bipolar disorder, schizophrenia, Alzheimer's, or dementia?

Yes No

Have you been hospitalized overnight in the past 2 years?

Yes No

Are you currently in a hospital, nursing home, hospice, or receiving in-home care?

Yes No

Which best describes it? (select all that apply)

Have you used illegal drugs, or been advised to have (or received) treatment or counseling for alcohol or drug use?

Yes No

Which applies? (select all that apply)

Alcohol treatment or rehab Drug treatment or rehab Recommended treatment/counseling but did not attend Currently in recovery / sober Illegal drug use (non-marijuana) Not sure / other

In the past 2 years, have you had any medical test, procedure, or hospitalization that has not been completed, or for which you have not yet received the results?

Yes No

Which applies? (select all that apply)

Awaiting test results Surgery or procedure scheduled but not yet done Hospitalization scheduled Follow-up recommended but not completed Not sure / other

Have you been diagnosed with a terminal illness or given a life expectancy of 24 months or less?

Yes No

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