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Unanswered Questions will be Highlighted in Red.

1. Select an age group: Select your age group 60-64 Years 65-69 Years 70-74 Years 75-79 Years 80-84 Years 85 Years and older

2. Please choose the gender:

Female Male

3. Body Mass Index (BMI) (weight in kg) / (height in m)2 [Calculate Your Body Mass Index Please CLICK HERE]

BMI 25 or greater BMI less then 25

4. Have you suffer form diabetes?

No Yes

5. Cancer (excluding minor skin cancers).

No Yes

6. Chronic lung disease that limits activities or requires oxygen use at home.

No Yes

7. Congestive heart failure.

No Yes

8. Cigarette smoking in the past week.

No Yes

9. Difficulty bathing/showering because of a health or memory problem.

No Yes

10. Difficulty managing money, paying bills, keeping track of expenses because of a health or memory problem.

No Yes

11. Difficulty pushing or pulling large objects like a living room chair because of a health problem.

No Yes

12. Difficulty walking several blocks because of a health problem.

No Yes