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To verify that you submitted this application please provide the name of the last school you attended. Name of the school    Confidential Health Survey 1. Your year of birth? (Required)    Ex:1951 2. What is your gender? (Required)       Male        Female 3. Does anyone in your household currently take any of the following medications? (Check ALL that apply)     Abilify Coreg CR Lantus Patanol Seroquel Accolate Crestor Levemir Paxil Singulair Aciphex Cymbalta Levitra Penlac Strattera Actonel Daytrana Lexapro Pepcid Some Actos Detrol Lialda Plavix Spiriva Adderall XR Diovan Lipitor Pravachol Symbicort Avodart Effexor XR Lotrel Premarin Synvisc Advair Enablex Lovaza Prempro Tamoxifen Albuterol Entecort Lovenox Prevacid Tekturna Allegra Evista Lucentis Prilosec Rx Toprol XL Altace Exelon Lunesta Pristiq Tricor Ambien Exforge Luvox CR Proscar Uroxatral Amitiza Fematra Lyrica Protonix Veramyst Arisept Flector Patch Macugen Provogil Viagra Arimidex Flovent Micardis Prozac Visudyne Asmanex Flonase Mirapex Pulmicort Vytorin Avandia Frova Nasacort Raptiva Vyvanse Astelin Geodon Nasalcrom Reclast Xalatan Boniva Glucophage Nasonex Relpax Xolair Byetta Glucotrol Namenda Remicade Xyzal Caduet Humalog Neulasta Reminyl Zegarid Celebrex Humira Neupogen Requip Zocor Chantix Humulin Nexium Restasis Zomig Cialis Imitrex Norvasc Rituxan     Cimzia Januvia Novolin Rozerem     Clarinex Keppra Novolog Sanctura XR     Concerta Lamictal Orencia Serevent     4. 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(Check ALL that apply)       Have Condition Take Drug For It     Have Condition Take Drug For It Aches/Pains   Erectile Dysfunction (ED) Acid Reflux/GERD   Gas/Intestinal bloating ADD (Adult)   Gastritis ADHD (Childhood)   Glaucoma Allergies   Headache Alzheimer's   Hearing difficulty Angina   Heart Attack Anxiety   Heart Desease Arthritis/Osteoarthritis   Heartburn Arthritis/Rheumatoid   High blood pressure Asthma (Adult)   high triglycerides Asthma (Childhood)   Hip Pain/Problems Atherosclerosis   Irritable Bowel Syn (IBS) Backache/pain   Macular degeneration Benign Prostate Hyperplasia   Menopause Bipolar Disorder   Migraine Birth control   Nail fungus Bladder control   Night Sweats/Hot Flashes Breast Cancer   OA of the Knee Cataract   Obesity Cholesterol Management   Osteoporosis Chronic bronchitis   Overactive Bladder Colorectal Cancer   Parkinson's Constipation   Peripheral Artery Disease COPD   Poor circulation Coronary Artery Disease   Prostate problems Crohn's Disease   Prostate cancer Deep Vain Thrombosis   Psoriasis Depression   Psoriatic Arthritis Diabetes Nerve Pain   Restless Legs Syn (RLS) Diabetes Type 1   Rosacea Diabetes Type 2   Shingles (past 6 months) Diarrhea   Skin Cancer Dry Eyes   Sleeplessness/Insomnia Dry Skin   Stroke Eczema   Sun damaged skin Emphysema   Ulcerative Colitis (UC) Enlarged Prostate   Ulcers Epilepsy   Weight control problems 8. Which of the following nonprescription products are used regularly in your household? (Check ALL that apply) Ache & pain reliever Adult incontinence protection Allergy remedies Antacids Anti-gas products Anti-diarrheal products Bran, high-fiber products Calcium supplements Cough & cold products Herbal supplements Laxatives Nutritional supplements Sleep-aid products Vitamins/minerals Nasal Decongestants Soy Products Smoking Cessation 9. I smoke Yes No 9a. If yes do you want to quit? Yes No 10. I exercise regularly Yes No 11. I own a pet Yes No 12. I am married Yes No 13. Do you have any children in your household? (Select one only)    Under 2 years old  2-5 years old  6-11 years old  12-17 years old  No children 14. Do you control your diet for the following? (Check ALL that apply)   Fat free High-fiber High-protein Lactose-free Low-calorie Low-carbohydrate Low-cholesterol Low-fat Low-sodium Natural or organic Sugar-free 15. Do you have: (Check ALL that apply)   Rx Drug Coverage Life Insurance Long Term Care Insurance Home Owners Insurance Auto Insurance 16. Does anyone in your household wear/use any of the following? (Check ALL that apply)   Blood Glucose Monitor 1-3 times/day Blood Glucose Monitor 4+ times/day High Blood Pressure Monitor Prescription eyeglasses/contacts Hearing aid 17. I get a flu shot annually Yes No Please check here if you do not wish to receive email offers from Remedy/MediZine, Inc.

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