Health Questionnaire to qualify for Life Insurance

Health Questionnaire

Health Questionnaire to qualify for Life Insurance

Please answer all the questions to qualify for the policy

Client Name:__________________

Agent Name:__________________

Proposed Death Benefit Amount:____________________

Type of Policy Seeking:__________________

Date of Birth:__________________



Do you use tobacco products?______________

If yes,What type of tobacco products do you use?

Does the client have any family history (parent, sibling) of death before age 70 due to cardiovascular, cerebral vascular disease, diabetes, or cancer?

If yes, please explain:________________________________________

Within the last 5 years has the client had a moving violation, reckless driving, or DUI/DWI?

If yes, please explain:____________________________________

Any prior convictions?  If so, please explain:_______________________________

Does the client participate in any dangerous activities/avocations (scuba diving, racing, skydiving, etc)?

If yes, please explain:_______________________________

List all prescription medications taken over the past 12 months.

  1. Medication: Amount            :                          Currently Taking?                             How Long Taking:                                                                   Reason Prescribed:                                                                                    
  2. Medication: Amount            :                          Currently Taking?                             How Long Taking:                                                                   Reason Prescribed:                                                                                    
  3. Medication: Amount            :                          Currently Taking?                             How Long Taking:                                                                   Reason Prescribed:                                                                                    
  4. Medication: Amount            :                          Currently Taking?                             How Long Taking:                                                                   Reason Prescribed:                                                                                    
  5. Medication: Amount            :                          Currently Taking?                             How Long Taking:                                                                   Reason Prescribed:                                                                                    

Have you ever been diagnosed by a licensed physician as having any of the following conditions?

(Circle all that apply)                   Yes                No      If yes, please fill out third page.

AIDS/HIV PositiveParkinson’s DiseasePeripheral Vascular Disease
Alzheimer’s DiseaseAlcohol AbuseRheumatoid Arthritis
Cancer (type)Drug AbuseSleep Apnea
COPD (emphysema)Epilepsy (type & date of last)High Blood Pressure (readings)
StrokesCirrhosisHigh Cholesterol (controlled)
Coronary Artery DiseaseAsthmaHeart Attack
Multiple SclerosisHepatitis (type)Aneurysm (location, size,
Crohn’s DiseaseIrregular Heart Rate/ Palpitationsoperated?)
Depression/AnxietyKidney Disease/FailureOrgan Transplants (type)
Diabetes (type)Lupus (type)Cardiovascular Disease

If you answered “YES” to any of the previous questions, provide full details here.

Diagnosis:                                                                                               Treatments:            

Date:                                                                                   Prognosis:             


Diagnosis:                                                                                                 Treatments:          

Date:                                                                                   Prognosis:             


Give details on any surgery or procedure. (i.e., angioplasty, bypass surgery, pacemaker, defibrillator)

Procedure:                                                                                                 Date:                                                                              

Treatment or Therapy:                                                                                                                                                      Residual Problems:                                                                                                                                                                                             

Typical Health Concerns and Medications for Life Insurance Policies


  1. Frequency of attacks or hospitalizations?
  2. Any oral steroids including inhalers that are steroidal?
  3. Smoker?
  4. Stable pulmonary function tests?
  5. Any diagnosis of COPD or emphysema?
  6. How long diagnosed?


  1. Where cancer originated?
  2. What stage of cancer, 1-4? 4 being metastasis and
  3. What kind of treatment and last date of treatment, if fully recovered (including surgery, radiation or chemotherapy?
  4. When diagnosed?
  5. PSA for prostate cancer <1?
  6. If melanoma need Clark level and depth of invasion?


  1. What medications, inhalers, and nebulizer?
  2. Does the client smoke?
  3. Need to know if the client has stable pulmonary function tests?
  4. Any hospitalizations?
  5. Any limitations or shortness of breath?
  6. Any oxygen use, daily steroid use or hospitalizations?
  7. When diagnosed?

Crohn’s disease

  1. When diagnosed?
  2. What treatment or meds is the client using?
  3. How frequent are flare-ups or hospitalizations?
  4. Wt stable?


  1. What type, 1 or 2?
  2. When diagnosed?
  3. How well controlled, last hemoglobin A1C?
  4. Any diabetic complications (neuropathy (nerve damage), retinopathy (eye), nephropathy (kidney damage), or circulatory problems?
  5. Wt and ht stable and w/in the guidelines?
  6. What medications, oral or insulin?
  7. Any heart conditions?

Heart disease

  1. Any heart surgeries, when and what type, bypass (# of bypasses), angioplasty, pacemaker, or heart valve replacement?
  2. Recovered?
  3. What medications taking?
  4. Any congestive heart failure/atrial fibrillation/heart attack/chest
  5. Is the client having regular follow-ups and/or testing (last seen and test results)


  1. What type? Discoid or systemic?
  2. When diagnosed?
  3. If systemic, what organs affected and how severe are they affected?
  4. What treatment or meds is the client using?
  5. How many flare-ups or hospitalizations?


  1. How many strokes?
  2. When was the episode?
  3. Any residuals, such as numbness, weakness, pain, slurred speech, or visual impairment?
  4. Any limitations that require cane or assistance?
  5. Any findings on a CT of white matter changes, small vessel disease, ischemic changes, micro vascular changes and lacunar infarcts?
  6. Any cognitive abnormalities?

Sleep Apnea

  1. When diagnosed?
  2. Severity of the condition?
  3. Does the client use a CPAP machine? Is the machine hooked to oxygen? If it is then companies will
  4. Any other treatment?
  5. Stable pulmonary function tests?