1. Are you over age 50?
   Yes    No
2. Do you smoke?
   Yes    No
3. Are you a cancer patient or cancer survivor who was treated with chemotherapy or radiation therapy?
   Yes    No
4. Have you been exposed to high doses of radiation from a nuclear reactor accident or atomic bomb blast?
   Yes    No
5. Are you a farm worker who has experienced long-term herbicide and/or pesticide exposure?
   Yes    No
6. Do you have any first-degree relatives (parents, siblings or children) who have developed chronic leukemia?
   Yes    No
7. Are you routinely exposed to harsh chemicals in the workplace, such as benzene (used as solvent and in motor fuel)?
   Yes    No

Sources: