1. How old are you?
   40 years or younger    41 to 49 years    50 to 64 years    65 years or older
2. Do you smoke?
   Yes    No
3. Are you often exposed to polluted or smoky environments?
   Yes    No
4. Did you get a flu shot this year?
   Yes    No
5. Have you recently received pneumonia vaccine (pneumonia shot)?
   Yes    No
6. Are you recovering from a recent cold or flu infection?
   Yes    No
7. Are you in frequent contact with people who are ill?
   Yes    No
8. Do you eat a healthy, balanced diet?
   Yes    No
9. Do you get plenty of rest and regular exercise?
   Yes    No
10. Do you have a chronic disease such as diabetes, lung disease, sickle cell anemia or kidney disease?
    Yes    No
11. Do you live in a nursing home or some other type of chronic care facility?
    Yes    No
12. Do you have HIV/AIDS or some other disease affecting the immune system?
    Yes    No
13. Are you taking drugs that suppress the immune system such as cyclosporine?
    Yes    No
14. Do you have frequent sinus infections?
    Yes    No
15. Do you have allergies?
    Yes    No

Source: