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Eligibility Questions

At any time, have you been medically diagnosed, treated, or had surgery for any of the following?

Do you have diabetes?

Within the past 36 months, have you been medically diagnosed, treated, or had surgery for any of the following?

Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?

Within the past 12 months, do any of the following apply to you?

Within the past 24 months if you have been medically diagnosed, treated, or had surgery for any brain, mental or nervous disorder, provide reason and diagnosis:

Within the past five years if you have been hospitalized, treated at an outpatient facility, or emergency room, provide reason and diagnosis:

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