Form PC-1789 Health History Form

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Current HHF Pages, Questions, and Subquestions
exported from MAXx on 9/26/2025 3:36:03 PM

1

Introduction Page
Page Type: Text Only Page Total Questions: 0 Last Updated On: 3/8/2021 by Hess, Peter

Health History Form
OMB Control Number 0420-0510
Expiration Date 02/29/2020, OMB renewal date pending.
The Peace Corps needs to assess your overall health status before you can be accepted to serve overseas. The
health history is the first step in the medical review process, which will take about an hour to complete. Your
signature at the end of the questionnaire certifies that you have answered all questions accurately and completely.
A health condition you manage easily at home in the U.S. can become a significant medical issue in many countries
where Peace Corps Volunteers serve. The Peace Corps Office of Medical Services assesses your health in the context
of living conditions and medical care in each country.
For this reason, the types of medical questions and the level of detail required are unlike other medical histories you
might normally be asked.
The Applicant Medical Screening Process is thorough, and it is important for you to answer all questions accurately.
On average, Peace Corps is able to medically clear more than 85% of all applicants.

Privacy Act Notice
Authority:  This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq.
Purpose:  It will be used primarily for the purpose of determining your eligibility for Peace Corps service and, if you
are invited to service as a Peace  Corps Volunteer,  for the purpose of providing you with medical care during your
Peace  Corps service. 
Routine Uses:  This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a(b), and
the Peace Corps' Routine Uses A through N, as listed on the Peace Corps’ Privacy Program webpage, and listed in
System of Records PC-17, “Volunteer Applicant and Service Records System.”  Among other uses, this information
may be used by those Peace Corps staff members who have a need for such information in the performance of their
duties. It may also be disclosed to the Office of Workers’ Compensation Programs in the Department of Labor in
connection with claims under the Federal Employees’ Compensation Act and, when necessary, to a physician,
psychiatrist, clinical psychologist, licensed clinical social worker or other medical personnel treating you or involved in
your treatment or care. 
Applicable SORN:  System of Records PC-17, Volunteer Applicant and Service Records System.
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Disclosure:  Your disclosure of this information is voluntary; however, your failure to provide this information or
failure to disclose relevant information may result in the rejection of your application to become a Peace Corps
Volunteer.

Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average 45 minutes per applicant. This
estimate includes the time for reviewing instructions and completing the collection of information. An agency may
not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1275 First
Street NE Washington, DC 20526 ATTN: PRA (0420 - 0510). Do not return the completed form to this address.

2

HIPAA Page
Page Type: Signature Page Total Questions: 2 Last Updated On: 12/2/2022 by Hess, Peter

HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law which, together with related
regulations, is designed in part to protect information about your health from unreasonable disclosure. It limits the
extent to which your “protected health information” — individually identifiable information about your physical or
mental health or the health care you have received — can be used without your consent for purposes other than
medical treatment and payment, and related business operations. Since the Peace Corps provides medical care to
Peace Corps Volunteers during their service, it is subject to HIPAA requirements. HIPAA requires individuals to be
given a notice describing how medical professionals and health plans use their medical information. The Peace
Corps’ notice is available on its website at www.peacecorps.gov/policies/pdf/hipaa.pdf
Since Peace Corps Volunteers often live and work in remote areas with less sophisticated sanitation and health-care
networks, and higher levels of endemic diseases than are typical in the United States, all applicants must receive
medical clearance before joining the Peace Corps. Your medical status may also have a bearing on the location of
your Peace Corps assignment. The Peace Corps needs access to information about your medical history and current
medical condition, including the answers you provide on this Health History Form and other information collected
during the Peace Corps’ medical clearance process, to determine whether you are medically eligible for Peace Corps
service and, if so, where you will be placed as a Volunteer.
Because HIPAA puts strict limits on the use of your protected health information, the Peace Corps must have a
signed authorization from you to use that information for purposes other than medical treatment and payment.
Therefore, unless you sign this authorization, the Peace Corps will not be able to consider your application for Peace
Corps service.
In addition, if you are offered and accept an invitation to become a Peace Corps Volunteer, the information collected
during the medical clearance process will become part of your Peace Corps medical record. The Peace Corps
medical staff will add information to your medical record as they care for you. As a Peace Corps Volunteer, the
Peace Corps will be responsible for your medical care and Peace Corps medical staff will, as permitted by HIPAA, use
your health information for medical treatment and payment. However, the Peace Corps has other responsibilities,
including training Volunteers, protecting their safety and security, providing program support to them overseas and
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ensuring that the whole Peace Corps system operates as effectively and efficiently as possible. There may, therefore,
be situations in which Peace Corps non-medical staff needs your health information for purposes other than medical
treatment or payment.
Under the Peace Corps’ medical confidentiality policy, your health information may be disclosed to Peace Corps
non-medical staff only if they have a specific need to know the information to do their jobs. This might include
situations in which the Country Director at your post needs medically confidential information in order to manage
the post. Only the minimum amount of information necessary will be disclosed and recipients are required to protect
the confidentiality of the health information they receive.
The following are some specific examples of health information that may be disclosed to Peace Corps non-medical
staff if they have a specific need to know the information to do their jobs:
•
•
•
•
•
•
•
•
•
•

Evidence of illegal or unauthorized drug use;
The existence of a medical condition for which you require accommodation, along with the nature of the
accommodation;
Information relating to a serious threat to your health or safety or that of any other person;
Information about your non-compliance with medical advice or policies that pose a serious risk of harm to
you or someone else;
The fact that you experienced a physical or sexual assault during your Peace Corps service (e.g. the Safety and
Security Manager would have a specific need to know);
Information needed to ensure proper arrangements for a medical evacuation;
Information about a medical condition if needed to ensure your safety and security or that of another person;
Information about a medical condition that is affecting your performance or well-being;
Information about risky sexual or other behavior that is putting you or someone else at serious risk; and
Information relating to your provision of any misleading, inaccurate or incomplete medical information to the
Peace Corps during the application process.

You may revoke this authorization at any time. However, because this authorization is needed in order for the Peace
Corps to administer its program, you may continue to serve as a Volunteer only for as long as this authorization
remains in effect.
This authorization permits the Peace Corps to use my protected health information to determine my eligibility for the
Peace Corps and as necessary for administration of the Peace Corps program. I understand that this document must
be signed, dated, and returned with my medical information, and that the Peace Corps will be unable to review my
information without this signed document.

I, {0} hereby authorize that:
A. All health information I provide to the Peace Corps or that is provided by anyone who has provided health care
services or treatment to me, consulted on such services, or otherwise has health care information responsive to the
information requests of the Peace Corps, including my response to the Health History form, and any follow-up
health information requested by and provided to the Peace Corps Office of Health Services relating to me prior to
my being sworn in as a Peace Corps Volunteer (including but not limited to information about my prior physical and
mental health history, my current health status, and possible future care and treatment), may be disclosed to the
following people:
Peace Corps staff, including in the Office of Health Services, Office of Volunteer Recruitment Selection, Office of
Global Operations, Office of Safety and Security, Office of General Counsel, Peace Corps Medical Officers, Country
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Directors at overseas posts, and any other Peace Corps staff or contractors who have a specific need to know the
information to perform their duties, for the purposes of making a determination of my medical or other eligibility for
Peace Corps service and of placement/assignment.
B. If I am accepted for Peace Corps service, the information listed above will become part of my Peace Corps health
record. All information in my Peace Corps health record, and any other personal health information relevant to me
that is provided to the Peace Corps by me or any health care provider or other person, may be disclosed to Peace
Corps staff or contractors, as described in paragraph A above, who have a specific need to know the information for
the purposes of performing their duties in connection with administration of the Peace Corps program only. This
may include (but is not limited to) information relevant to my continued service as a Peace Corps Trainee or Peace
Corps Volunteer.
This authorization is effective until five years following either my close of Peace Corps service or final determination
by the Peace Corps that I am not eligible for Peace Corps service. I understand that I may revoke this authorization
at any time by sending a written revocation to the Office of Health Services, Peace Corps, 1275 First Street NE,
Washington, DC 20526, but that my revocation before acceptance will stop consideration of my application, and that
my service as a Volunteer is conditioned on the existence of this authorization, which is necessary to administer the
Peace Corps program.
I also understand that during the entire period of this authorization to use my health care information, Peace Corps
will protect the confidentiality of my health care information, consistent with the Privacy Act, the Health Insurance
Portability and Accountability Act (as applicable), and Peace Corps policies on confidentiality of medical information,
as described in the Peace Corps Notice of Privacy Practices and Peace Corps Manual Section 268.

I have read and understand this authorization.
1 Applicant Name
Question Type: Single Line Of Text Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

2 Date of Birth
Question Type: Date Time Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

3

Opening Questions Page
Page Type: Questions Page Total Questions: 11 Last Updated On: 8/24/2020 by Hess, Peter

1 What sex were you assigned at birth?
Question Type: Select one of these options: Female, Male
Last Updated On: 9/26/2025 by Hess, Peter

Display to: All Applicants

2 What is your height? (In Feet and Inches)

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Question Type: Numerical Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

3 How much do you weigh? (In Pounds)
Question Type: Numerical Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

4 Have you been hospitalized overnight, including for observation, in the past five
years?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Dates of hospitalization?
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Diagnosis
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Do you visit a health-care provider for a medical, mental health, or dental
condition more frequently than every four months? For example, medication check,
laboratory testing, follow-up care, etc.
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

6 Are you restricted from having some or all vaccinations?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

7 Do you or have you ever used nicotine or tobacco products including but not
limited to: cigarettes, cigars, dissolvable/oral or smokeless products, electronic
cigarettes or vape pens, water pipes or hookahs?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

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9 Do you require or use an artificial limb or prosthetic device for any part of your
body?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Please describe the prosthetic device you require
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 11/4/2024 by Hess, Peter

10 Do you currently use a removable partial or a full denture?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

11 Do you currently have symptoms of temporomandibular joint disease (TMD)
such as jaw pain, difficulty chewing, or locking of the jaw joint, or do you use an
occlusal or night guard to prevent teeth grinding or discomfort?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

12 Are you over 74 years of age?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

4

Surgeries Page
Page Type: Questions Page Total Questions: 5 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you had surgery in your lifetime?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Please provide a list of your surgeries
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had surgery on your brain or spinal cord?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

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3 Do you have any retained hardware (e.g., pins, rods, joint replacement, or
other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

4 Have you ever had any surgery or procedure on your lungs?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had bariatric surgery?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Was your bariatric procedure a sleeve gastrectomy?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5

Medications Page
Page Type: Questions Page Total Questions: 7 Last Updated On: 8/24/2020 by Hess, Peter

1 Do you regularly take any medications, including prescription, over-the-counter,
supplements or herbal remedies for any medical condition? Please include any
contraception i.e. pills, IUD, or implant.
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List all medications you are currently taking. If you do not know the strength of a
medication, please answer "unknown". As you complete this questionnaire, make sure
you report each health condition for which you take prescription medication.
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Do you take benzodiazepines (e.g., Xanax/Alprazolam, Valium/Diazepam,
Ativan/Lorazepam, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you take injectable medications?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

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4 Do you take immunosuppressive/immunomodulator medications (e.g.,
prednisone, azathioprine, methotrexate, Humira, Syriza or others)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

5 Do you take blood thinning medication (e.g ., Xarelto, Eliquis, Lovenox, Pradaxa,
Coumadin, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

6 Do any of your medications require refrigeration?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

7 Do you currently take or plan to take HIV PrEP (Pre-exposure Prophylaxis) during
service?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

6

Allergies Page
Page Type: Questions Page Total Questions: 11 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you ever been prescribed an EpiPen?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

2 Do you currently receive allergy shots/oral sublingual therapy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Expected date of final treatment
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you have an allergy to 3 or more antibiotics?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Please list the three antibiotics you are allergic to

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Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Please describe your reaction
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you have a penicillin/amoxicillin allergy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Name of medication
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Please describe your reaction
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Do you have other medication allergies?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Name of medication(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Do you have a peanut allergy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 How are you currently managing this condition?
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Please describe your reaction
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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7 Do you have a tree nut allergy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 How are you currently managing this condition?
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Please describe your reaction
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Do you have a shellfish allergy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 How are you currently managing this condition?
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Please describe your reaction
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Do you have a finned-fish (tilapia, flounder, salmon, tuna, catfish, anchovy or
other fish with fins) allergy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 How are you currently managing this condition?
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Please describe your reaction
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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10 Do you have any other life-threatening allergies (allergies that cause swelling of
the mouth/tongue/lips, difficulty breathing, loss of consciousness, and/or a drop in
blood pressure) not listed above?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List the other severe allergy or allergies
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Do you have other allergies not listed above (e.g., other foods, bee/wasp/insect,
animal, dust, mold, pollen, trees, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List the other allergy or allergies
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7

Cancer Page
Page Type: Questions Page Total Questions: 19 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you ever had melanoma?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
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Question Type: Single Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had basal cell carcinoma?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever had squamous cell carcinoma?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 12 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Have you ever had any other skin cancer?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had cancer or malignancy of your ear, nose or throat (e.g., cancer
of the throat, mouth, tongue, salivary glands, neck, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 13 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever had thyroid cancer?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever had any other cancer or carcinoma of the endocrine system?
(e.g., pituitary gland, parathyroid glands, thymus, pancreas, adrenal glands, or
other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?

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Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Have you ever had cancer or carcinoma of the gastrointestinal tract (e.g.,
esophagus, stomach, duodenum, liver, gall bladder, pancreas, appendix, small
intestines, colon, rectum, mesentery, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Have you ever had cancer or carcinoma of the blood, circulatory system, or
lymphatic system?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis

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Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Have you ever had bone or muscle cancer?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 16 of 150

11 Have you ever had a tumor (cancerous or non-cancerous) of the brain or spinal
cord?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Have you ever had lung cancer?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Page 17 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 Have you ever had cancer of the prostate or testicle?
Question Type: True/False Display to: Applicants with Birth Sex Male only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 Have you ever had cancer of the bladder or kidney?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 18 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever had breast cancer?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

16 Have you ever had uterine cancer or endometrial cancer?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?

Page 19 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

17 Have you ever had ovarian cancer?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

18 Have you ever had vaginal or vulvar cancer?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 20 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

19 Have you ever had any other gynecological cancer, not listed above?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8

Cardiology Page
Page Type: Questions Page Total Questions: 24 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you ever had a heart or major vessel surgery or procedure (e.g., coronary
artery angioplasty, stents, coronary artery bypass graft (CABG), carotid artery
endarterectomy, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Page 21 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had coronary heart disease (e.g., carotid artery occlusion,
stenosis, angina pectoris, myocardial infarction (heart attack), coronary artery
disease, or other)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 22 of 150

3 Do you have congestive heart failure?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you have cardiomyopathy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

Page 23 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had endocarditis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever had pericarditis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 24 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Do you have a pacemaker?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of surgery/implant
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Do you have an implanted defibrillator?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of surgery/implant
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?

Page 25 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Have you ever had an aortic or cardiac aneurysm?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Do you have Marfan syndrome?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 26 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever had recurrent fainting, syncope, or loss of consciousness?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Have you ever had atrial fibrillation, atrial flutter or, Wolfe-Parkinson-White
syndrome?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Page 27 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 Have you ever had any other heart irregularity or heart conduction disorder
(e.g., heart/bundle branch block, palpitations, irregular rhythm, tachycardia,
bradycardia, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 Have you ever had a heart murmur?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis

Page 28 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever had any other heart valve condition not listed above (e.g., aortic
stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, mitral valve
prolapse, pulmonary stenosis, pulmonary regurgitation, tricuspid stenosis, tricuspid
regurgitation, valve replacement (or need for), or other)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 29 of 150

16 Have you ever had any structural heart defect (e.g., patent foramen ovale
(PFO), atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus
arteriosus (PDA), or other)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

17 In the past two years have you been evaluated or treated for high blood
pressure?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 30 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

18 Have you ever been evaluated or treated for high cholesterol or high
triglycerides?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

19 Have you ever been evaluated or treated for peripheral vascular disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 31 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

20 In the past two years have you been evaluated or treated for varicose veins
(symptomatic or painful)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

21 Have you ever been evaluated or treated for Raynaud's syndrome?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 32 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

22 Have you ever had an EKG?
Question Type: True/False Display to: Applicants Less than 50 years old
Last Updated On: 10/11/2024 by Hess, Peter

23 Have you ever had an EKG?
Question Type: True/False Display to: Applicants Greater than and equal to 50 years old
Last Updated On: 10/11/2024 by Hess, Peter

24 Have you ever had any other condition, procedure, defect, or disease of the
heart or major vessels not listed above that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List the other condition(s), procedure(s), defect(s), or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9

Dermatology Page
Page Type: Questions Page Total Questions: 10 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you ever had any skin lesion(s) that required excision, monitoring and/or
treatment (e.g., actinic keratosis, or other pre-cancerous skin tumor or lesion)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of removal
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?

Page 33 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had or been treated for a pilonidal cyst?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever been diagnosed or treated for rosacea?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 34 of 150

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Have you ever been diagnosed or treated for psoriasis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 In the past two years have you been diagnosed or treated for acne?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis

Page 35 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever you been diagnosed or treated for serious hair loss (alopecia)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you been treated within the past two years?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 36 of 150

7 In the past two years have you been diagnosed or treated for a lipoma?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 In the past two years have you been diagnosed or treated for eczema?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

Page 37 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 In the past 6 months have you been diagnosed or treated for non-genital warts?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Have you ever had any other condition or disease of the skin not listed above
that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10

Ear, Nose, and Throat Page
Page Type: Questions Page Total Questions: 9 Last Updated On: 8/24/2020 by Hess, Peter

Page 38 of 150

1 Please select current hearing status
Question Type: Select one of these options: I have no issues with hearing,I am hard of hearing,I am deaf
All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

Display to:

1 What is your primary means of communication?
Question Type: Select one of these options: I use spoken English as my primary means of communication, I
use American Sign Language as my primary means of communication, I use a combination of spoken
English and American Sign Language as my means of communication Display when answer to parent
question is I am hard of hearing
Last Updated On: 10/11/2024 by Hess, Peter

2 Ear(s) affected
Question Type: Select one of these options: Left, Right, Both
am hard of hearing
Last Updated On: 10/11/2024 by Hess, Peter

Display when answer to parent question is I

3 Have you had a hearing evaluation (such as audiometry)?
Question Type: True/False Display when answer to parent question is I am hard of hearing
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you use hearing aid(s)?
Question Type: True/False Display when answer to parent question is I am hard of hearing
Last Updated On: 10/11/2024 by Hess, Peter

5 Do you currently use support modalities and/or assistive technology to manage daily
activities and work?
Question Type: True/False Display when answer to parent question is I am hard of hearing
Last Updated On: 10/11/2024 by Hess, Peter

6 If applicable, do you require electricity for charging your hearing aid(s)?
Question Type: True/False Display when answer to parent question is I am hard of hearing
Last Updated On: 10/11/2024 by Hess, Peter

7 What is your primary means of communication?
Question Type: Select one of these options: I use spoken English as my primary means of communication, I
use American Sign Language as my primary means of communication, I use a combination of spoken
English and American Sign Language as my means of communication Display when answer to parent
question is I am deaf
Last Updated On: 10/11/2024 by Hess, Peter

8 Ear(s) affected
Page 39 of 150

Question Type: Select one of these options: Left, Right, Both
am deaf
Last Updated On: 10/11/2024 by Hess, Peter

Display when answer to parent question is I

9 Do you have cochlear implants?
Question Type: True/False Display when answer to parent question is I am deaf
Last Updated On: 10/11/2024 by Hess, Peter

10 Do you currently use support modalities and/or assistive technology to manage daily
activities and work?
Question Type: True/False Display when answer to parent question is I am deaf
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever been diagnosed or treated for a vocal cord disorder?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever had any non-cancerous growth(s) of your ear, nose, throat,
mouth, tongue, vocal cords, salivary glands, or neck (e.g., acoustic neuroma,
cholesteatoma, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis

Page 40 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 In the past two years have you been diagnosed or treated for vertigo (dizziness
or sensation of room spinning)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 41 of 150

5 In the past two years have you been diagnosed or treated for ringing in the ear
(tinnitus)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 In the past two years have you been diagnosed or treated for chronic/recurrent
ear infection?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Page 42 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 In the past two years have you been diagnosed or treated for chronic/recurrent
sinusitis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 In the past two years have you been diagnosed or treated for chronic tonsillitis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 43 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Have you ever had any other condition of the ear, nose, or throat not listed
above that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11

Endocrinology Page
Page Type: Questions Page Total Questions: 14 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you ever had a disease or condition of the pituitary gland?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 44 of 150

2 Have you ever had a disease or condition of the adrenal glands (e.g.,
pheochromocytoma, congenital adrenal hyperplasia, Cushing's disease, Addison's
disease, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever had hypothyroidism (low or underactive thyroid)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 45 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Have you ever had a non-cancerous tumor affecting the endocrine system (e.g.,
pituitary gland, parathyroid glands, thymus, pancreas, adrenal glands, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had hyperthyroidism (high or overactive thyroid)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 46 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever had a disease or condition of the thyroid gland (e.g., Hashimoto's
disease, Grave's disease, thyroid storm, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever had a disease or condition of the parathyroid gland (e.g.,
hypoparathyroid, hyperparathyroid, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 47 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Have you ever had diabetes mellitus, type 1 (juvenile diabetes) or any type of
diabetes which required treatment with insulin?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you currently manage your Diabetes Mellitus, Type 1 with an insulin pump?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 48 of 150

9 Have you ever had diabetes mellitus, type 2 or any type of diabetes that
required treatment with dietary and lifestyle modifications and/or oral or injectable
medication (other than insulin)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you require injectable (by a shot) medication either daily or as needed for this
condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Have you ever been diagnosed or treated for a glucose disorder, other than
diabetes mellitus (e.g., hypoglycemia (low glucose), pre-diabetes, hyperglycemia
(high glucose), or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 49 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever been evaluated or treated for osteoporosis or osteopenia?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had a fracture due to this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Have you ever had any other hormone disorder not previously listed (e.g.,
growth, reproductive, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Page 50 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 In the past two years have you been diagnosed or treated for any conditions
requiring hormonal therapy for conditions such as hypogonadism (low testosterone
or low estrogen and progesterone), low libido or taken hormonal therapy?
Question Type: True/False Display to: All Applicants
Last Updated On: 1/31/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 51 of 150

14 Have you ever had any other endocrine condition not listed above that
required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12

Gastroenterology Page
Page Type: Questions Page Total Questions: 20 Last Updated On: 8/24/2020 by Hess, Peter

1 Do you have cirrhosis of the liver?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had any other diseases of liver (e.g., fatty liver, alcohol-related
liver injury, sarcoid liver, malaria, parasitic disease, gall bladder-related Issues,
Gilbert's disease/syndrome, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Page 52 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you have ulcerative colitis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 53 of 150

4 Do you have Crohn's disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Do you have inflammatory bowel disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

Page 54 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever been evaluated or treated for irritable bowel syndrome?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever had a colostomy or ileostomy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Have you ever had a history of stricture, obstruction, abscess, or fistula of the
gastrointestinal tract?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Have you ever had esophageal varices or tears?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
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Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever had an anal fissure?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Do you have a lactose intolerance?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 Do you have a gluten intolerance?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Do you have Celiac Disease?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 In the past five years have you been evaluated or treated for acute pancreatitis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis

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Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

16 In the past two years have you been evaluated or treated for a hernia (e.g.,
hiatal, abdominal, inguinal, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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17 In the past two years have you been evaluated or treated for gastroesophageal
reflux disease (GERD, heartburn)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

18 In the past five years have you been evaluated or treated for a peptic ulcer (a
mucosal break in the stomach or small intestine)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
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Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

19 In the past two years have you been evaluated or treated for gastritis
(inflammation of the mucosa of the stomach)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

20 Have you ever been evaluated or treated for diverticulitis (inflammation of the
lining of the colon)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

21 In the past two years have you been evaluated or treated for hemorrhoids
(internal or external)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

22 Have you ever had any other gastrointestinal condition not listed above that
required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13

Hematology Page
Page Type: Questions Page Total Questions: 15 Last Updated On: 8/24/2020 by Hess, Peter

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1 Have you ever had leukemia?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had lymphoma?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

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Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever had multiple myeloma?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you have hemophilia or von Willebrand disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had a bleeding or clotting disorder (e.g., deep vein thrombosis,
factor V Leiden, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Were you born without a spleen, had your spleen removed or have a partially
functioning spleen or other splenic abnormality?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 65 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Do you have sickle cell disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Do you have sickle cell trait?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 66 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Do you have thalassemia or thalassemia trait?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Do you have hemoglobin C?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?

Page 67 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Do you have hemochromatosis (iron overload)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Do you have aplastic anemia?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 68 of 150

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 Do you have hemolytic anemia?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 In the past two years have you been diagnosed or treated for anemia (e.g., iron
deficiency, pernicious anemia, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Page 69 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever had any other blood condition or disorder not listed above that
required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14

Immunology and Rheumatology Page
Page Type: Questions Page Total Questions: 15 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you ever had ankylosing spondylitis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 70 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had systemic lupus erythematosus?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever had polymyositis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?

Page 71 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Have you ever had dermatomyositis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had scleroderma (systemic sclerosis or CREST syndrome) or
localized scleroderma (morphea or linear scleroderma)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 72 of 150

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever had psoriatic arthritis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever had fibromyalgia?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis

Page 73 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Have you ever had chronic fatigue syndrome?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 74 of 150

9 Have you ever had rheumatoid arthritis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Have you ever had juvenile idiopathic arthritis (juvenile rheumatoid arthritis)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

Page 75 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever had vasculitis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Have you ever been diagnosed or treated for gout?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 In the past five years have you been evaluated or treated for reactive arthritis
(arthritis that arises following an infection, e.g. Reiter's syndrome, lyme arthritis)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 Have you ever had Sjogren's syndrome?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 77 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever had any other rheumatologic or immunologic condition or
disorder not listed above that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15

Infectious Disease Page
Page Type: Questions Page Total Questions: 24 Last Updated On: 8/24/2020 by Hess, Peter

1 Do you have human immunodeficiency virus (HIV)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 78 of 150

2 Have you ever had hepatitis A?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever had hepatitis B?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

Page 79 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Have you ever had hepatitis C?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had any other or unknown hepatitis not listed above?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 80 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever had a positive TB/PPD skin test or positive TB blood test (latent
tuberculosis infection)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition or were you treated in the past?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever had active tuberculosis disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition or were you treated in the past?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 81 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Do you have symptoms of Post-Covid Conditions (PCC)? (Also known as longCOVID or chronic COVID?)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Have you ever been diagnosed or treated for syphilis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 82 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 In the past two years have you been diagnosed or treated for genital warts?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever been diagnosed or treated for herpes or Mpox (formerly known
as monkeypox)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Page 83 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 In the past two years have you been diagnosed or treated for gonorrhea?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 In the past two years have you been diagnosed or treated for chlamydia?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 84 of 150

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 In the past two years have you been diagnosed or treated for any other sexually
transmitted infection (STI)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever been diagnosed with shingles?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Page 85 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

16 In the past five years have you been diagnosed or treated for any chronic,
frequent, or recurrent bacterial, fungal, or viral infection, including thrush, cellulitis,
skin abscesses, MRSA infections (methicillin resistance in staphylococcus aureus)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 86 of 150

17 Have you ever been diagnosed or treated for dengue fever?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

18 In the past two years have you been diagnosed or treated for Lyme disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

Page 87 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

19 Have you ever been diagnosed or treated for malaria?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

20 In the past two years have you been diagnosed or treated for amoebas
(amebic dysentery)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 88 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

21 In the past two years have you been diagnosed or treated for giardia?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

22 In the past two years have you been diagnosed or treated for mononucleosis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?

Page 89 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

23 In the past two years have you been diagnosed or treated for Epstein-Barr
virus?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

24 Have you ever had any other infectious or parasitic disease, condition, or
symptom not listed above that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

16

Mental Health Page
Page Type: Questions Page Total Questions: 24 Last Updated On: 9/2/2021 by Hess, Peter

Page 90 of 150

1 Have you ever been prescribed a medication for a mental health condition
(antidepressant, anti-anxiety, sleep medication, mood stabilizer, anti-psychotic,
medication for ADHD, etc.)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Enter Mental Health Medications
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you had a change in your mental health medication regimen (type, dose,
frequency, starting or stopping etc.) in the past 24 months?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you currently take three or more medications (including as-needed medication)
related to your mental health concerns?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Do you currently take or have taken in the past 5 years Concerta, Focalin, Ritalin,
or any similar or generic methylphenidate?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you currently take or have taken in the past 5 years Adderall, Dexedrine,
Vyvanse, or any similar or generic amphetamine?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

4 Have you ever had, periods of increased energy/decreased need for sleep
followed by depression, mood swings or other bipolar-related symptoms?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 91 of 150

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever experienced, been diagnosed or treated for auditory or visual
hallucinations, a psychotic episode, schizoaffective disorder, schizophrenia, or
other?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever been treated or diagnosed for a dissociative-related concern
(dissociative amnesia disorder, dissociative identity disorder, or other?)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 92 of 150

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever had any period of prolonged sadness, hopelessness, or other
depression-related concerns or symptoms?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Have you ever had chronic or excessive worry, panic, or other anxiety concerns?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
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Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Have you ever had significant attention/concentration concerns or been
diagnosed with ADD/ADHD?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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10 Have you ever had any obsessive thoughts and/or compulsive behaviors (e.g.,
engaging in repetitive behaviors and repetitive thought patterns, excessive fear of
germs, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever had extreme startle reactions, flashbacks, nightmares, feeling
numb, intrusive memories, or other PTSD-related concerns or symptoms?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Have you ever been diagnosed or treated for a personality or conduct disorder
(antisocial personality disorder, borderline personality disorder, oppositional defiant
disorder, or other?)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 Have you ever had alcohol or substance use-related concerns or difficulties
(e.g., unsuccessful attempts to cut down, blackouts, injury to self or others while
under the influence, others have expressed concerns about your use)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
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3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 Have you ever had any eating or body image concerns or symptoms (e.g.,
extreme restriction of food intake, self-induced vomiting after meals, excessive
exercise, binge eating, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever had any sleep disturbances? (e.g. insomnia, hypersomnia, sleep
walking, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

16 Have you ever been diagnosed with a somatic or pain disorder (conversion
disorder, somatization disorder, or other?)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

17 Have you ever cut, scratched, burned, hit yourself, or engaged in other selfinjurious behavior?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
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Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

18 Have you ever had thoughts of not wanting to live, ending your life, or
someone else’s?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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19 Have you ever been evaluated and/or treated for mental health concerns in
the following treatment settings: a) Residential hospitalizationb)
Inpatient hospitalizationc) Partial hospitalization program (PHP)d)
Intensive outpatient (IOP) or rehabilitation programe) Emergency
department/emergency room/urgent caref) Crisis center
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of hospitalization
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

20 In the past five years, have you been to counseling or therapy services (this
includes in-person or virtual, including email or text)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of last visit
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

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Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

22 In the past five years, have you received mental health services other than
therapy/counseling (for example, bio/neuro-feedback, hypnosis, Reiki, etc.)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of last service
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently receiving this service?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

23 Have you ever been diagnosed or treated for Autism Spectrum Disorder
(previously known as Autistic Disorder, Asperger Syndrome, Pervasive
Developmental Disorder Not Otherwise Specified, Disintegrative Disorder)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

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Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

24 Has anyone expressed concern about your memory, or have you experienced
dementia-like symptoms or been diagnosed with dementia?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Did you seek care for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

25 Have you ever had any other mental health symptom or condition not listed
above that required you to seek care?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of onset
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
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17

Musculoskeletal Page
Page Type: Questions Page Total Questions: 11 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you ever had any diseases of the bone, including bone tumors (e.g.,
Paget's disease, fibrous dysplasia, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 In the last two years have you been evaluated or treated for a condition (injury
or pain) of the muscle(s), bone(s), tendon(s), or ligament(s) of the back or spine?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?

Page 103 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 In the last two years have you been evaluated or treated for a condition (injury
or pain) of the muscle(s), bone(s), tendon(s), or ligament(s) of the head or neck?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 In the last two years have you been evaluated or treated for a condition (injury
or pain) of the muscle(s), bone(s), tendon(s), or ligament(s) of the shoulder, arm,
wrist, hand, or fingers?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?

Page 104 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 In the last two years have you been evaluated or treated for a condition (injury
or pain) of the muscle(s), bone(s), tendon(s), or ligament(s) of the hip/pelvis, leg,
knee, ankle, foot, or toe?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 In the last two years have you been evaluated or treated for any other condition
(injury or pain) of the muscle(s), bone(s), tendon(s), or ligament(s)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis

Page 105 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever been evaluated or treated for degenerative disc disease (changes
to the spinal discs)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 106 of 150

8 Have you ever been evaluated or treated for degenerative joint disease
(osteoarthritis)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Have you ever been evaluated or treated for scoliosis (curvature of the spine)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
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Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Have you ever been evaluated or treated for kyphosis (bowing of the spine)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever had any other muscle, bone, tendon, or ligament condition not
listed above that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

18

Neurology Page
Page Type: Questions Page Total Questions: 13 Last Updated On: 8/24/2020 by Hess, Peter

Page 108 of 150

1 Have you ever had a condition involving the blood vessels in your brain (e.g.,
brain aneurysm, cerebral vascular accident, stroke-like symptom, transient ischemic
attack, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had a ventricular shunt placed?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of surgery/implant
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever had a seizure, seizure disorder, or epilepsy (other than a seizure
caused by a high fever as a young child)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you have any neuromuscular disorder, motor abnormality, or movement
disorder (including tics) (e.g., amyotrophic lateral sclerosis (ALS), multiple sclerosis,
Parkinson's disease, myasthenia gravis, cerebral palsy, muscular dystrophy, postpolio syndrome, Tourette's syndrome, tremors, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
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3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had a concussion or traumatic brain injury?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Do you have narcolepsy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?

Page 111 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Do you have a history of sleep walking after the age of 18 years
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Have you ever had restless leg syndrome?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 In the past two years have you been evaluated or treated for loss of
consciousness or fainting?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 113 of 150

10 Have you ever been evaluated or treated for migraine headaches, severe
headaches, frequent headaches (4 or more headaches per month) or do you
currently have migraines or other severe headaches?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever been evaluated or treated for Guillian-Barre symptoms or
syndrome?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Have you ever been evaluated or treated for peripheral neuropathy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 Have you ever had any other condition of the brain or nervous system not listed
above that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

19

Ophthalmology Page
Page Type: Questions Page Total Questions: 18 Last Updated On: 8/24/2020 by Hess, Peter

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1 Do you have partial blindness in either eye?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Do you have complete blindness in either eye?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

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Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you have macular degeneration?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you have diabetic retinopathy?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Do you have any ocular lesions (a growth in the eye; e.g. nevus, pinguecula,
pterygium, or other) that require scheduled exams?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever had retinal detachment?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 118 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever had inflammation of the middle layer of the eye or uvea? (e.g.
uveitis)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Have you ever had optic nerve disease (e.g., optic neuritis)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 119 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Do you wear glasses or contact lenses?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Do you need contact lenses for an ocular condition that cannot be treated with
glasses?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 Have you had vision correction surgery such as LASIK?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 120 of 150

11 Have you ever been diagnosed or treated for temporary blindness?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Have you ever been diagnosed or treated for herpes infection of the eye (e.g.,
ocular herpes, shingles, keratitis, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Page 121 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 Have you ever been diagnosed or treated for lattice degeneration?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 Have you ever been diagnosed or treated for retinitis pigmentosa?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 122 of 150

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever been diagnosed or treated for cataracts?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

16 In the past two years have you been diagnosed or treated for any eyelid
condition (e.g., chalazion, hordeolum, stye, conjunctivitis, blepharitis, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 123 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

17 Have you ever been diagnosed or treated for glaucoma?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

18 Have you ever had any other eye symptom or condition not listed above that
required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

20

Reproductive Health Page
Page Type: Questions Page Total Questions: 22 Last Updated On: 2/7/2022 by Hess, Peter

Page 124 of 150

1 Do you want to receive a routine screening mammogram while in service?
Question Type: Select one of these options: I would like to have a routine mammogram screening during my service.,I
would like to waive my routine mammogram while in service. Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

2 Have you ever had a mammogram or breast sonogram?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

3 Have you ever had an abnormal mammogram or breast sonogram?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please check the option below that describes your most recent pap smear or
human papilloma virus (HPV) test result. (An abnormal result is any abnormal pap
smear and/or the presence of high-risk HPV.)
Question Type: Select one of these options: Normal, Abnormal, Never had a Pap
Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

Display to: Applicants with Birth

1 Do you need a repeat or follow-up Pap and/or HPV test and/or colposcopy in the
next year due to a previous abnormal HPV test or pap smear (not a regularly scheduled
exam for routine screening)?

Page 125 of 150

Question Type: True/False Display when answer to parent question is Normal
Last Updated On: 10/11/2024 by Hess, Peter

2 Do you need a repeat or follow-up Pap and/or HPV test and/or colposcopy in the
next year due to a previous abnormal HPV test or pap smear (not a regularly scheduled
exam for routine screening)?
Question Type: True/False Display when answer to parent question is Abnormal
Last Updated On: 10/11/2024 by Hess, Peter

5 Do you currently have breast implants?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of surgery
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Type of implant
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Do you currently use a contraceptive?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Please select the contraception method you use below
Question Type: Option set Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 In the past two years have you been evaluated or treated for abnormal
menstrual cycles (e.g., no bleeding, infrequent bleeding, heavy or painful bleeding)?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?

Page 126 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 In the past five years have you been evaluated or treated for a breast lump?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 In the past five years have you been evaluated or treated for solid breast mass?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 127 of 150

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 In the past two years have you been evaluated or treated for fibrocystic breast?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever been evaluated or treated for polycystic ovarian disease?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis

Page 128 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 In the past five years have you been evaluated or treated for ovarian cyst(s)?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 129 of 150

13 In the past five years have you been evaluated or treated for endometriosis
(uterine lining growing outside of uterus)?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 In the past five years have you been evaluated or treated for endometrial
hyperplasia (excessive proliferation of the uterine lining)?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Page 130 of 150

Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever been treated for a Bartholin's gland mass (benign tumor or
cancer), swelling (cyst) or infection (abcess)?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you been treated within the past two years?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

16 In the past five years have you been diagnosed with and/or treated for uterine
fibroids (leiomyomas)?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

17 Have you ever been evaluated or treated for undescended testicle?
Question Type: True/False Display to: Applicants with Birth Sex Male only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

18 In the past two years have you been evaluated or treated for hydrocele?
Question Type: True/False Display to: Applicants with Birth Sex Male only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?

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Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

19 In the past two years have you been evaluated or treated for spermatocele?
Question Type: True/False Display to: Applicants with Birth Sex Male only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

20 Have you ever been evaluated or treated for varicocele?
Question Type: True/False Display to: Applicants with Birth Sex Male only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

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3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

21 In the past two years have you been treated with hormone replacement therapy
for menopause or amenorrhea?
Question Type: True/False Display to: Applicants with Birth Sex Female only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

22 Have you ever had any other reproductive health condition not listed above
that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List the other condition(s), procedure(s), defect(s), or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

21

Respiratory Page
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Page Type: Questions Page Total Questions: 9 Last Updated On: 8/24/2020 by Hess, Peter

1 Do you have chronic obstructive pulmonary disease (COPD) (emphysema and/or
chronic bronchitis) bronchiectasis, or recurrent pneumonia (more than twice in the
past 3 years)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had pulmonary embolism?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
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4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Have you ever had fibrotic lung disease (e.g., lung scarring including sarcoidosis,
lupus, idiopathic pulmonary fibrosis, or other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you have cystic fibrosis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
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Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Have you ever had pulmonary hypertension?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever had asthma (including exercise induced), reactive airway disease
(RAD), or wheezing?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 How many years has it been since you last used or were prescribed an asthma inhaler
(albuterol, ProAir, Proventil, Ventolin, Levalbuterol, Xopenex)?
Question Type: Option set Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
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3 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever been evaluated or treated for a partial or total lung collapse
(pneumothorax)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 Have you ever had sleep apnea?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
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Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Do you use a CPAP machine?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

5 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 Have you ever had any other respiratory symptom or condition not listed above
that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

22

Urology and Nephrology Page
Page Type: Questions Page Total Questions: 15 Last Updated On: 8/24/2020 by Hess, Peter

1 Have you ever had a kidney transplant?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 139 of 150

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Have you ever had kidney and/or ureteral stones?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you have a solitary or horseshoe kidney?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis

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Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you have polycystic kidney disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 141 of 150

5 Have you ever had inflammation of the kidney (glomerulonephritis/nephritis)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

6 Have you ever had renal failure or acute or chronic kidney disease?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe

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Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

7 Have you ever had chronic bladder or pelvic pain (e.g., interstitial cystitis, or
other)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

8 In the past two years have you been evaluated or treated for recurrent cystitis,
recurrent pyelonephritis, or other recurrent infections of the urinary tract? (Note:
recurrent includes two episodes in a six-month period or more than two episodes in
the last two years)
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Page 143 of 150

Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

9 In the past two years have you been evaluated or treated for bladder cystocele
(weakened, stretched bladder)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

10 In the past two years have you been evaluated or treated for incontinence (loss
of urinary control)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter
Page 144 of 150

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

11 Have you ever been evaluated or treated for enlargement of the prostate gland
(benign prostatic hypertrophy)?
Question Type: True/False Display to: Applicants with Birth Sex Male only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

12 Have you ever been evaluated or treated for a ureteral or urethral stricture
(narrowing, scarring or blockage in the tubes that carry urine to your bladder or out
of your body)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

Page 145 of 150

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

13 In the past two years have you been evaluated or treated for neurogenic
bladder?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Date of diagnosis
Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

14 Have you ever been evaluated or treated for a prostate nodule?
Question Type: True/False Display to: Applicants with Birth Sex Male only
Last Updated On: 9/26/2025 by Hess, Peter

1 Date of Diagnosis
Page 146 of 150

Question Type: Month/Year Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

2 Are you currently being treated for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you require a specialist for monitoring and/or follow-up for this condition?
Question Type: True/False Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

4 Please Describe
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

15 Have you ever had any other urology or nephrology symptoms or conditions
not listed above that required you to seek medical attention?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 List other condition(s) or disease(s)
Question Type: Grid Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

23

Closing Questions Page
Page Type: Questions Page Total Questions: 15 Last Updated On: 8/24/2020 by Hess, Peter

2 Do you have a condition for which you require academic support or an
accommodation plan to learn or work during Peace Corps service?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

3 Do you have any limitation that prevents you from walking distances greater
than two miles on rough or uneven terrain on a daily basis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

4 Do you have any limitation that prevents you from biking distances greater than
two miles on rough or uneven terrain on a daily basis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter
Page 147 of 150

5 Do you have any limitation that prevents you from climbing at least two flights of
stairs carrying groceries or luggage without difficulty on a daily basis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

6 Do you have any limitation that prevents you from holding a squat position for
several minutes to use a squat commode or toilet?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

7 Are you unable to tolerate riding in a vehicle on rough roads on a daily basis?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

8 Do you have any limitation that prevents you from lifting and/or managing your
luggage and other supplies during service (up to a weight of 50 pounds)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

9 Are you unable to tolerate living in conditions of extreme heat (>90 degrees),
extreme cold (<20 degrees), constant dampness, and/or constant dust?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

10 Do you have any medical condition(s) that would prohibit you from living at
high altitudes (more than 5,000 feet above sea level)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Please describe the medical condition
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 11/4/2024 by Hess, Peter

11 Do you have any limitation on your ability to perform activities of daily living
(self-care activities such as eating, bathing, dressing)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Please describe the limitations
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 11/4/2024 by Hess, Peter

Page 148 of 150

2 Please describe the accommodation(s) you require
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 11/4/2024 by Hess, Peter

12 Do you have any other chronic or active condition(s) or conditions that require
monitoring (labs, imaging or exams) that are not previously listed or described?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

13 Do you use any medical equipment (either daily or as needed) that has not
been previously listed?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

14 Based on a condition or conditions you have listed in this questionnaire, do you
believe you will need special medical support?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

15 Based on a condition or conditions you have listed in this questionnaire; do you
believe you will need special medical or other types of support?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

16 Does your physical stature require special furniture or other accommodations to
support your stature (i.e. height or weight)?
Question Type: True/False Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

1 Please describe:
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 11/4/2024 by Hess, Peter

2 Please describe the accommodation(s) you require:
Question Type: Multi Line of Text Display when answer to parent question is Yes
Last Updated On: 10/11/2024 by Hess, Peter

24

Diagnosis Verification Page
Page Type: Summary Page Type Total Questions: 0 Last Updated On: 8/24/2020 by Hess, Peter

25

Final Signature Page
Page 149 of 150

Page Type: Signature Page Total Questions: 2 Last Updated On: 8/24/2020 by Hess, Peter

I confirm that all of my previous answers were truthful and complete to the best of my knowledge.

1 Applicant Name
Question Type: Single Line Of Text Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

2 Date of Birth
Question Type: Date Time Display to: All Applicants
Last Updated On: 10/11/2024 by Hess, Peter

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