Medical Questionnaire for Quotes Full Name:* Phone*Email Medical QuestionsHeight*4'10"4'11"5'0"5'1"5'2"5'3"5'4"5'5"5'6"5'7"5'8"5'9"5'10"5'11"6'0"6'1"6'2"6'3"6'4"6'5"6'6"6'7"6'8"6'9"6'10"6'11"7'0"Weight:* Date of Birth* MM slash DD slash YYYY What type of prescription medications are you currently taking? Were any parents/siblings diagnosed before age 70 of heart disorder or cancer? Yes No Please specify relation/diagnosis age/age of death or current age Has a member of the medical profession ever treated you for or diagnosed you with:High blood pressure, heart attack, coronary artery disease, a heart valve disorder, heart murmur, irregular heartbeat, a stroke, circulatory disease, an aneurysm or any disease of the heart or blood vessels? Yes No Diagnosis/Date of diagnosis/Cardiac procedures performed, if bypass or stents # of vessels:Anemia or blood abnormality? Yes No Diagnosis/Date of diagnosis:Polyp, cyst, tumor, cancer, leukemia, melanoma, lymphoma or Hodgkin’s disease? Yes No Type/Date of diagnosis/Stage/Type and date of last treatment:Diabetes, high blood sugar, glucose intolerance or other endocrine disorder? Yes No Diagnosis/Date of diagnosis/A1c/Oral or injectable:Anxiety, depression or any other mental or psychiatric illness? Yes No Diagnosis/Date of diagnosis:Asthma, emphysema, sleep apnea, sarcoidosis or any disorder of the lungs or respiratory system? Yes No Diagnosis/Date of diagnosis/Use C-Pap/Other:Ulcer, hepatitis, ulcerative colitis, Crohns disease, or any other disorder of the esophagus, liver, stomach or intestines? Yes No Diagnosis/Date of diagnosis:A seizure, epilepsy, Parkinson’s disease, Alzheimer’s or any other disorder of the brain or nervous system? Yes No Diagnosis/Date of diagnosis:Nephritis, polycystic kidney disease, elevated PSA, or any other disorder of the bladder, kidney, urinary tract or prostate? Yes No Diagnosis/Date of diagnosis:Osteoarthritis, back trouble, or disorder of the joints, muscles, bones? Yes No Diagnosis/Date of diagnosis/Pain medications:Lupus, rheumatoid arthritis, chronic fatigue syndrome, fibromyalgia or any other disease or disorder of the autoimmune system? Yes No Diagnosis/Date of diagnosis/Pain medications:In the past 5 years have you used any type of nicotine or marijuana use?(cigarettes, chewing tobacco, vaping, cigars) Yes No Date last used/Type/Frequency:Have you had or been advised to have treatment or counseling for alcohol or drug use or been asked to reduce or eliminate their usage? Yes No Type/Date of last treatment:Other than what has been disclosed, have you:Been declined or rated for life insurance? Yes No Date/Reason/Insurance Company:Been a patient in a hospital or other medical facility, other than for normal childbirth? Yes No Please specify:Had any other disease, disorder or condition? Yes No Please specify:Been advised to have surgery, medical tests or diagnostic procedures? Yes No Please specify:Non-Medical QuestionsIn the past five years, have you flown as a pilot, student pilot or do you intend to become a pilot? Yes No Instrument Rated/Hours per year/Total hours:In the past five years, have you participated in any activities such as motorized vehicle racing, SCUBA diving, mountain climbing, skydiving, extreme sports such as BASE jumping, bungee jumping or cave exploration, or do you intend to? Yes No Please specify:In the past five years, have you had your driver’s license denied, suspended or revoked? Yes No Please specify:In the past five years, have you been convicted of or pled guilty to driving under the influence of alcohol and/or drugs? Yes No Please specify:In the past five years, have you been convicted of or pled guilty to any moving violations? Yes No Please specify:Will you live or travel outside the United States within the next 12 months? Yes No Destination/Duration/Personal or Business:Within the past 10 years, have you been arrested, convicted, or imprisoned for any crime and/or are you currently awaiting trial for any crime? Yes No Please specify:CommentsThis field is for validation purposes and should be left unchanged.