Are you confined to a wheelchair or motorized mobility device?
Are you currently hospitalized, confined to a nursing home or assisted living facility?
Are you currently receiving occupational or physical therapy?
Have you ever been diagnosed with or been treated for any of the following?
Chronic kidney disease or kidney failure
emphysema, COPD, or other pulmonary disorder requiring oxygen
Alzheimer’s, Dementia, or other cognitive disorder
parkinsons, multiple sclerosis, or lou gehrig’s disease
AIDS or organ transplant
Do you have diabetes with complications including retinopathy, neuropathy, or any related heart disorder?
Do you have a cardiac defibrillator implanted
In the past 2 years have you been treated or advised by a doctor to have treatment for any of the following?
coronary artery disease, angina, heart attack, cardiac angioplasty, bypass surgery, or stent placement
cardiomyopathy, congestive heart failure, aortic or cardiac aneurysm, peripheral vascular disease, endarterectomy, cartoid artery disease, heart or heart valve disorder, atrial fibrillation, other heart rhythm disorder, or pacemaker implanted
alcoholism or drug abuse
internal cancer, lymphoma or melanoma
stroke or TIA
Have you been advised by a medical professional that surgery may be required within the next 12 months for cataracts?
Do you currently have any lung or respiratory disorder and currently use tobacco products?
Has a doctor recommended any further treatment, surgery, or tests that has not yet been completed?