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:__________________
Height:____________
Weight:______________
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.
- Medication: Amount : Currently Taking? How Long Taking: Reason Prescribed:
- Medication: Amount : Currently Taking? How Long Taking: Reason Prescribed:
- Medication: Amount : Currently Taking? How Long Taking: Reason Prescribed:
- Medication: Amount : Currently Taking? How Long Taking: Reason Prescribed:
- 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 Positive | Parkinson’s Disease | Peripheral Vascular Disease |
Alzheimer’s Disease | Alcohol Abuse | Rheumatoid Arthritis |
Cancer (type) | Drug Abuse | Sleep Apnea |
COPD (emphysema) | Epilepsy (type & date of last) | High Blood Pressure (readings) |
Strokes | Cirrhosis | High Cholesterol (controlled) |
Coronary Artery Disease | Asthma | Heart Attack |
Multiple Sclerosis | Hepatitis (type) | Aneurysm (location, size, |
Crohn’s Disease | Irregular Heart Rate/ Palpitations | operated?) |
Depression/Anxiety | Kidney Disease/Failure | Organ 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:
Medications:
Diagnosis: Treatments:
Date: Prognosis:
Medications:
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
Asthma
- Frequency of attacks or hospitalizations?
- Any oral steroids including inhalers that are steroidal?
- Smoker?
- Stable pulmonary function tests?
- Any diagnosis of COPD or emphysema?
- How long diagnosed?
Cancer
- Where cancer originated?
- What stage of cancer, 1-4? 4 being metastasis and
- What kind of treatment and last date of treatment, if fully recovered (including surgery, radiation or chemotherapy?
- When diagnosed?
- PSA for prostate cancer <1?
- If melanoma need Clark level and depth of invasion?
COPD/Emphysema
- What medications, inhalers, and nebulizer?
- Does the client smoke?
- Need to know if the client has stable pulmonary function tests?
- Any hospitalizations?
- Any limitations or shortness of breath?
- Any oxygen use, daily steroid use or hospitalizations?
- When diagnosed?
Crohn’s disease
- When diagnosed?
- What treatment or meds is the client using?
- How frequent are flare-ups or hospitalizations?
- Wt stable?
Diabetes
- What type, 1 or 2?
- When diagnosed?
- How well controlled, last hemoglobin A1C?
- Any diabetic complications (neuropathy (nerve damage), retinopathy (eye), nephropathy (kidney damage), or circulatory problems?
- Wt and ht stable and w/in the guidelines?
- What medications, oral or insulin?
- Any heart conditions?
Heart disease
- Any heart surgeries, when and what type, bypass (# of bypasses), angioplasty, pacemaker, or heart valve replacement?
- Recovered?
- What medications taking?
- Any congestive heart failure/atrial fibrillation/heart attack/chest
- Is the client having regular follow-ups and/or testing (last seen and test results)
Lupus
- What type? Discoid or systemic?
- When diagnosed?
- If systemic, what organs affected and how severe are they affected?
- What treatment or meds is the client using?
- How many flare-ups or hospitalizations?
Stroke/CVA/TIA
- How many strokes?
- When was the episode?
- Any residuals, such as numbness, weakness, pain, slurred speech, or visual impairment?
- Any limitations that require cane or assistance?
- Any findings on a CT of white matter changes, small vessel disease, ischemic changes, micro vascular changes and lacunar infarcts?
- Any cognitive abnormalities?
Sleep Apnea
- When diagnosed?
- Severity of the condition?
- Does the client use a CPAP machine? Is the machine hooked to oxygen? If it is then companies will
- Any other treatment?
- Stable pulmonary function tests?