Personal Medical History Section 1

1. Date of Birth

2. Arm dominance

3. If over 20, please indicate the maximum and minimums since the age of 18. (If under age 20, go to question 4)
	maximum height (in inches)
	maximum weight (in pounds)
	minimum weight (in pounds)

4. Your major ancestry (You may mark more than one)
	Asian/Pacific Islander Black Scandinavian Caucasian (non-Hispanic)	American Indian Hispanic Other (specify)

5. Are you now or have you ever been married?

YES NO

	5.1 If yes, how many times have you been married?
	5.2 What is your current marital status

5.3 If married or committed, how long?

	5.4 Number of children

6. Highest Education Level Attained

	6.1 Mark all degrees completed	associates baccalaureate masters doctorate other

7. Are you now or have you in the past served in the Armed Forces?

YES NO

	7.1 If yes, indicate branch	Army Navy Marines	Coast Guard National Guard Air Force

	7.2 Dates (4-digit years) served	-

7.3 Were you ever stationed abroad?

YES NO

If so, where?

8. Present Household, Dwelling Type (check all that apply):
	city country suburb	apartment single family house mobile home	condo/townhouse duplex other (specify)

9. Present occupation: What is your present work situation? (check all that apply)
	employed full-time employed full-time, plus part-time employed part-time self-employed	unemployed semi-retired fully-retired homemaker	student on disability other (specify)