Please answer the following questions.

1. Do you have a job, or have you recently had a job, where you were frequently exposed to any of the following: exhaust fumes, asbestos, radon, excessive smoke, second hand tobacco smoke, industrial solvents, pesticides, or any other air pollutant not listed?

2. Do you live in close proximity (within a mile) to a busy freeway?

3. Do you regularly smoke tobacco products?

4. If you answered yes to question 3, tell us how many cigarettes (or use of other tobacco products) you might smoke in a day?

5. Is the city, town, or rural area in which you live, do you have periods of high air pollution?