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Anyone using tobacco
products? If so, who? |
| Anyone participating in hazardous
sports or activities such as racing, rock climbing, etc.? If so, who and what? |
| Anyone with major health problems?
If so, who and what? |
| Anyone
taking any medications? If so, who and what? |
| Does any one use a cane, walker or
wheel chair? |
| In the past 5 years, has anyone been
confined to home, needed home care or previously been in an
assisted living facility or nursing facility If yes, who &
for how long under care? |
| Comments,
questions or special needs: |
