Now, please click to select the conditions which currently apply to ANYONE IN YOUR HOUSEHOLD, OTHER THAN YOU. Please check as many as apply.

Allergies - nasal Allergies - other Alzheimer's Anxiety Arthritis Asthma Baldness / hair loss Bladder control / incontinence Cancer: breast Cancer: prostate Cancer: other Chronic back pain Depression

Diabetes type 1 Diabetes type 2 Frequent heartburn Frequent headaches Hearing loss Heart disease or angina High blood pressure High cholesterol Impotence / E.D. Migraines Osteoporosis Physical handicap Sleep difficulty Yeast infection

Do YOU YOURSELF currently take any of the following prescription drugs? Please check as many as apply.

Allegra Calan Celebrex Celexa Claritin Flonase Glucotrol Herbal remedies Insulin - injection Insulin - oral Lipitor Lopressor

Methotrexate Mevacor Nasacort Necon Norvasc Ortho Tri-Cyclen Paxil Pravachol Premarin Prempro Propecia Proventil

Prozac Rogaine Synthroid Viagra Vioxx Wellbutrin Xanax Xenical Zantac Zocor Zoloft Zyrtec

Finally, does ANOTHER MEMBER OF YOUR HOUSEHOLD currently take any of the following prescription drugs? Please check as many as apply.

Allegra Calan Celebrex Celexa Claritin Flonase Glucotrol Herbal remedies Insulin - injection Insulin - oral Lipitor Lopressor

Methotrexate Mevacor Nasacort Necon Norvasc Ortho Tri-Cyclen Paxil Pravachol Premarin Prempro Propecia Proventil

Prozac Rogaine Synthroid Viagra Vioxx Wellbutrin Xanax Xenical Zantac Zocor Zoloft Zyrtec

Which of the following best describes your health plan? An HMO, where your health plan pays only for medical care received if you go to one of the doctors from their plan. If you go to an outside doctor they will not pay any part of the cost unless their own doctor referred you or you had a medical emergency. In an HMO you generally have a primary care physician. A PPO or preferred provider organization, a plan that pays some part of the cost no matter which doctor you go to, but you pay more of the cost if you see a doctor who is not on the plan's list. A traditional plan, where you can go to any doctor and the plan pays the same percent of the cost no matter which doctor you choose. Other No health coverage How many hours do you spend on the internet each week, NOT including time you spend on e-mail? Less than 5 hours per week 5-16 hours per week More than 16 hours per week