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First Name *
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1) Do you currently need or receive assistance or supervision performing everyday living activities, such as walking, bathing, dressing, eating, transferring or toileting?
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2) Are you currently confined to a hospital, nursing home, assisted living facility are you receiving any type of care or assistance in your home?
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3) Do you use oxygen continuously or a walker or a wheelchair more than once per week?
Select your answer here:	Yes No
4) Have you ever been diagnosed with or treated for:
Mental Retardation, Alzheimers Disease, Dementia, Senility or any type of Organic Brain Syndrome or Disorder, Schizophrenia, or consulted a physician about memory loss, forgetfulness or confusion?	Yes No
Acquired Immune Deficiency Syndrome (AIDS) or AIDS-related Complex (ARC), or tested positive for the Human Immunodeficiency Virus (HIV)?	Yes No
ALS (Amyotrophic Lateral Sclerosis or Lou Gehrings Disease), Cerebral Palsy, Charcot Marie Tooth, Cystic Fibrosis or Muscular Dystrophy?	Yes No
5) Have you ever tested positive for Huntingtons Chorea?
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