Number of therapy sessions per week:___________
Name of drug connection in case of medical emergency:
Sex: [ ] Male [ ] Female [ ] Formerly Male [ ] Formerly Female [ ] Both
[ ] Other________
If female, indicate breast implant size: ________
Will the size of your implants hinder your ability to safely operate a motor vehicle? [ ] Yes [ ] No
Males: [ ] Blonde [ ] Red [ ] Black [ ] Brown [ ]Other _________
Females: [ ] Blonde [ ] Platinum Blonde [ ] Ash Blonde [ ] Strawberry Blonde
Teenagers: [ ] Red [ ] Orange [ ] Green [ ] Purple [ ] Blue [ ] Fuchsia [ ]Teal [ ]Combination [ ]Skinhead [ ] Other________
Activities you perform while driving (check all that apply):
[ ] Eating
[ ] Drinking Starbucks coffee
[ ] Applying makeup
[ ] Shaving
[X] Talking on the phone (already checked for your convenience)
[ ] Lifting weights
[ ] Applying cellulite treatment to thighs
[ ] Tanning
[ ] Snorting cocaine
[ ] Watching TV
[ ] Reading Variety
[ ] Surfing the net
Medications you are taking:
[ ] Prozac
[ ] Zovirax
[ ] Lithium
[ ] Zanax
[ ] Valium
[ ] Medical marijuana
[ ] Zoloft
[ ] Viagra
[ ] Estrogen
[ ] All of the above
[ ] None of the above
If none, please explain: ___________________________________
Length of daily commute:
[ ] 4 hours or longer
[ ] 3 hours
[ ] 2 hours
[ ] 1 hour
[ ] less than 1 hour
If less than 1 hour, please explain:
If you are the victim of a carjacking, you should:
[ ] Call the police to report the crime.
[ ] Call Channel 9 News to report the crime, then watch your car on the news in a high-speed chase.
[ ] Call your attorney and discuss lawsuit against cellular phone company for your 911 call not going through.
[ ] Let them shoot you since law-abiding citizens are not permitted to carry a gun.
In the event of an earthquake, you should:
[ ] Stop your car.
[ ] Keep driving and hope for the best.
[ ] Use your cell phone to call your loved ones.
[ ] Pull out your video camera and obtain footage for Channel 9.
In the event of rain, you should:
[ ] Never drive over 5 MPH.
[ ] Drive twice as fast as usual.
[ ] Drive as close to the curb as possible to help spread the water onto sidewalks and pedestrians.
[ ] Stop traffic to raise convertible top.
When you see a driver with her arm extended out the window, it means:
[ ] Her turn signals are broken.
[ ] She intends to change lanes.
[ ] She’s drying her nails.
Automatic door locks are good for:
[ ] Security
[ ] Convenience
[ ] Messing with the heads of people trying to get in
The “bright” setting on your headlights is for:
[ ] Poorly lit roads at night
[ ] Flashing to get the car ahead to move out of the way
[ ] Revenge
When stopped by police, you should:
[ ] Pull over and have your driver’s license and insurance form ready.
[ ] Try to outrun them.
[ ] Have your video camera ready and provoke them to attack, thus ensuring yourself a hefty legal settlement.