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Plan Your Future
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Health Questionnaire Pre-Screen

  • Agent Information
  • Proposed Policy
  • Client Information
  • Medical Questions
  • Medications
  • Name of DrugDosageFrequencyWhen PrescribedReason 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?
  • 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?
  • 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?
  • MM slash DD slash YYYY
  • 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?
  • If yes - provide details
  • Do you have a handicapped parking tag?
  • If yes - why?
  • Have you ever been turned down for any insurance coverage?
  • If yes - give type of insurance, date and reason
  • Cancer History
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • pre-PSAcurrent PSAGleason Score
  • Diabetes History
  • MM slash DD slash YYYY
  • (retinopathy, neuropathy, nephropathy)
  • Heart Disease History
  • If yes, please provide details
  • MM slash DD slash YYYY
    If yes, please provide date
  • MM slash DD slash YYYY
    If yes, please provide date
  • MM slash DD slash YYYY
    If yes, please provide date
  • MM slash DD slash YYYY
    If yes, please provide date
  • MM slash DD slash YYYY
    If yes, please provide date
  • MM slash DD slash YYYY
    If yes, please provide date
  • Lung Disorder History
  • (asthma, bronchitis, COPD, emphysema, etc)
  • Mental Illness/Depression History
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
    If yes, date:
  • Bone, Joint, or Muscular Problems
    Surgery/joint replacements or recommended surgery in the past 5 years?
    Any history of joint injections in the last 5 years?
    Do you have any joint deformities?
    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 MemberConditionAge of Diagnosis 
  • 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.
  • This field is for validation purposes and should be left unchanged.
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