Pre-Underwriting QuestionnairePlease answer all questions applicable to the client's medical history. Questions? Call Jim or Teresa at 877.564.1707. Producer Name*Phone*Email* Date Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseType Has the case been submitted to other companies in the last 12 months?YesNoIf yes, list companies, dates, and action taken: Date of last routine physical: Date Format: MM slash DD slash YYYY Please list any health conditions. Please list any medications being taken (including over-the-counter). Height:Weight:Average weight change in past 12 months: Latest blood pressure reading:Date Date Format: MM slash DD slash YYYY Cholesterol/HDL results:Date Date Format: MM slash DD slash YYYY Family history: Has any immediate family member (parents or siblings) had death or disease up to age 65 from cancer, diabetes, cerebrovascular disease, or heart disease? If yes, complete the information below.Click the + sign to add additional relatives. Relation (Mother, Father, Brother, Sister)Type of DiseaseIf Cancer, Type of CancerAge of OnsetAge at Death (if Deceased) Alcohol/Drug Abuse?YesNoCurrent user?YesNoDuration used:Date stopped using:Kind of substance:Amount used:Type of treatment:Attend AA/NA or other programs?YesNoAny relapses?YesNoAny motor vehicle violations or DUIs?YesNoIf yes, provide details: Asthma/COPDYesNoWhen diagnosed?Number of attacks per year:Date and severity of last attack:Are attacks seasonal?YesNoAny hospitalizations?YesNoIf yes, when? AviationYesNoTotal hours flown as pilot or co-pilot:IFR?YesNoHours flown per year:Type of license:Purpose (civilian, military, etc.): Cancer?YesNoTypeLocationStagingGrading or copy of pathology reportAny positive lymph nodes?YesNoDepth, level, or Gleason ScoreDate of surgery Date Format: MM slash DD slash YYYY Any radiation or chemo?YesNoIf yes, date treatment endedAny recurrence of cancer?YesNoIf yes, provide details Cardiac DisordersYesNoMI (heart attack)Any History of?Date of OnsetTreatment GivenIrregular heart beatAny History of?Date of OnsetTreatment GivenValve disorderAny History of?Date of OnsetTreatment GivenCoronary artery diseaseAny History of?Date of OnsetTreatment GivenDate of last cardiologist visit: Date Format: MM slash DD slash YYYY Reason:Date of last stress test: Date Format: MM slash DD slash YYYY Results:Date of most recent echocardiogram: Date Format: MM slash DD slash YYYY Results: Ever Have?Coronary catheterizationDateResultsEver Have?Bypass surgery (CABG)DateResults# of vesselsEver Have?Angioplasty (PTCA)DateResults# of vesselsEver Have?Valve surgery or replacementDateResultsWhich valve?Ever Have?StentingDateResultsWhich vessels? Crohns?YesNoColitis?YesNoDate diagnosed: Date Format: MM slash DD slash YYYY Any hospitalizations or surgery?YesNoIf yes, what? Diabetes?YesNoDate diagnosed? Date Format: MM slash DD slash YYYY Treatment (oral meds, insulin, diet):Units of insulin:Names of medications:Number of regular doctor visits per year:Any complications:Last fasting blood sugar and date:Last glycohemoglobin (A1c) and date: Foreign Travel/Foreign ResidenceYesNoCitizenship:Type of VisaDoes client have a green card?YesNoAnswer the following if the client is not a US citizen:How long in the US?Works in the US?Owns property in the US?US bank account?Travel outside the US:Click the + sign to add additional trips. CountryCityDuration of stayFrequencyPurpose of Travel Hepatitis?Type AType BType CDate diagnosed: Date Format: MM slash DD slash YYYY Cause:Current status:ActiveCuredMedications/date of last use:Current alcohol use/amount: Hypertension?YesNoDate diagnosed: Date Format: MM slash DD slash YYYY Average readings:Are readings monitored at home?YesNo Lab Abnormalities?YesNoWhat tests were abnormal?Results/date(s):Any diagnosis given:How long has test been abnormal? Multiple Sclerosis?YesNoLupus?YesNoDate diagnosed: Date Format: MM slash DD slash YYYY Last attack:Attack frequency:How long do attacks last?Any disability? Mental Disorders/Depression/AnxietyYesNoDiagnosis:Date Date Format: MM slash DD slash YYYY Hospitalization?YesNoSuicide attempt(s)?YesNoCurrently employed?YesNo Seizure Disorder/Epilepsy?YesNoDate of last seizure: Date Format: MM slash DD slash YYYY Date of diagnosis: Date Format: MM slash DD slash YYYY Type of seizure:Frequency of seizures: Sleep Apnea?YesNoDate diagnosed: Date Format: MM slash DD slash YYYY Is CPAP used every night?YesNoDate of last sleep study: Date Format: MM slash DD slash YYYY Sleep study results: Mild Moderate Severe Was surgery done?YesNoIf yes, type: TIA/CVA (transient ischemic attack-ministroke/stroke)?YesNoDate of episode: Date Format: MM slash DD slash YYYY Number of episodes:Any residuals:Type of treatment/medication: Avocations (scuba, mountain climbing, etc.)?YesNoSpecify: Impairments not listed?YesNoDiagnosis given:Date Date Format: MM slash DD slash YYYY Treatment:Medications:Date of last followup: Date Format: MM slash DD slash YYYY Test results: For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. 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