Health Questionnaire Pre-Screen

Agent Information
Agent Name*
First Last
Agent Phone Number*
Agent Email Address*
Proposed Policy
Monthly Benefit
Benefit Duration
Riders Requested (Please List)
Resident State
Partnership
- Yes
- No
Client Information
Client's Name
First Last
State
- Male
- Female
DOB
MM
DD
YYYY
Tobacco User
- Yes
- No
If so, please indicate the type and frequency. If quit, indicate last use.
Does the client have a spouse or significant other with whom they reside?
- Yes
- No
Medical Questions
Have you ever been diagnosed with or treated for one of these conditions? (check all that apply)
- Diabetes requiring Insulin
- Peripheral Vasuclar Disease
- Carotid Artery Disease
- Skin Ulcers
- Stroke or Transient Ischemic Attack (TIA)
- Alzheimer's Disease, Lewy Body Disease or Dementia
- Psychosis or Schizophrenia
- Mental Retardation
- Amyotrophic Lateral Scleosis (ASL) or Myasthenia Gravis
- Multiple Sclerosis
- Parkinson's Disease or Parkinsonism
- Post-Polio Syndrome
- Demyelinating Disease
- Lupus (SLE)
- Mixed Connective Tissue Disease
- Scleroderma
- Muscular Dystrophy
- Amputation-Due to Disease
- Double Heart Valve Replacement
- Organ or Bone Marrow Transplants
- Kidney Disease or Polycystic Kidney Disease
- Cirrhosis of the Liver
- Hepatitis B, C, D or E
- Hemachromatosis
- Metastatic Cancer
- Multiple Myeloma
- Brain or Spinal Cord Tumors
- AIDS
- Neurological Conditions affecting the brain or spinal cord
- Muscular Conditions Causing Functional Limits
Medications
Check here if you DO NOT TAKE ANY MEDICATIONS
Name of Drug Dosage Frequency When Prescribed Reason for Taking

Record all medications you currently take including prescription medications and any over the counter drugs.
Have you been prescribed any medication you are not taking?
Prescribed Medications Not Taking
- Yes
- No
If yes - provide details (i.e. name of medication, who prescribed, for what condition, why not taking it:
Do you have any surgeries planned or recommended?
Surgeries
- Yes
- No
If yes - provide details of type of surgery and when it is scheduled
When was the last time you saw your primary physician and why?
Date Last Seen
Date Format: MM slash DD slash YYYY
Reason:
List any specialists you have seen in the last 5 years.
Type of Specialist: Month/Year last seen: Reason for Visit
Have you ever been on disability?
Disability
- Yes
- No
If yes - provide details
Do you have a handicapped parking tag?
Parking Tag
- Yes
- No
If yes - why?
Have you ever been turned down for any insurance coverage?
Turned down for coverage
- Yes
- No
If yes - give type of insurance, date and reason
Cancer History
Have you ever been diagnosed with cancer?
- Yes
- No
Type
Date Diagnosed
Date Format: MM slash DD slash YYYY
Treatment
Stage
Grade
Lymph Node Involvement
Date of Last Treatment
Date Format: MM slash DD slash YYYY
Any Recurrence?
- Yes
- No
If prostate cancer, please include
pre-PSA current PSA Gleason Score
Diabetes History
Type
- Type I
- Type II
Date Diagnosed
Date Format: MM slash DD slash YYYY
Medications
A1C
Any Complications
(retinopathy, neuropathy, nephropathy)
Heart Disease History
Do you have heart conditions?
- Yes
- No
Heart Attack
- Yes
- No
If yes, please provide details
Stroke
- Yes
- No
Date Format: MM slash DD slash YYYY

If yes, please provide date
TIA
- Yes
- No
Date Format: MM slash DD slash YYYY

If yes, please provide date
Bypass Surgery?
- Yes
- No
Date Format: MM slash DD slash YYYY

If yes, please provide date
Angioplasty?
- Yes
- No
Date Format: MM slash DD slash YYYY

If yes, please provide date
Pacemaker?
- Yes
- No
Date Format: MM slash DD slash YYYY

If yes, please provide date
Defibrillator?
- Yes
- No
Date Format: MM slash DD slash YYYY

If yes, please provide date
Lung Disorder History
Do you have lung problems?
- Yes
- No
Type of Disorder
(asthma, bronchitis, COPD, emphysema, etc)
Treatment
Severity
Frequency of Attacks
Dates of hospitalizations/ER visits
Mental Illness/Depression History
Have you had mental health problems or depression?
- Yes
- No
Name of condition
Date Diagnosed
Date Format: MM slash DD slash YYYY
Severity
Treatment
Seeing a psychiatrist/psychologist?
Attempted suicide?
Suicide Date
Date Format: MM slash DD slash YYYY

If yes, date:
Hospitalizaton due to depression?
Bone, Joint, or Muscular Problems
Surgery/joint replacements or recommended surgery in the past 5 years?
- Yes
- No
Surgery/joint replacements or recommended surgery in the past 5 years?
- Yes
- No
Any history of joint injections in the last 5 years?
Do you have any joint deformities?
- Yes
- No
Do you have any joint deformities?
Are you currently in physical therapy or using any medical equipment (i.e. cane, walker, crutches)?
- Yes
- No
Are you currently in physical therapy or using any medical equipment (i.e. cane, walker, crutches)?
To the best of your knowledge, has your biological mother, father or sibling been diagnosed with coronary heart disease or any form of dementia (e.g. Alzheimer’s Disease)?
Family Members
Family Member Condition Age of Diagnosis
Additional Information
Other
Additional Information
Please include any Health History that was not covered in above areas. Also, include any additional information that you may have regarding the above areas. If this is a rush, please indicate when needed by. For certain risk assessments, we are at the mercy of the carriers to get back to us. Please allow extra time so we can fi nd you the best carrier given the information provided.
Email
This field is for validation purposes and should be left unchanged.

Name of Drug	Dosage	Frequency	When Prescribed	Reason for Taking

Type of Specialist:	Month/Year last seen:	Reason for Visit

Family Member	Condition	Age of Diagnosis