Life Insurance Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Any form of tobacco or nicotine use in the last 5 years? *YESNOProvide detailsPlease list your height and weight *Immediate family history: Has your mom/dad/sibling passed away or been diagnosed before 65 of heart disease, cancer or diabetes? *YESNOPlease describe:Medications (dosage amount and frequency): *Are there any medications or treatments that have been prescribed that you are not taking? *YESNOWhich ones?Have any medical procedures been recommended to you that are scheduled – or should be scheduled? *YESNOProcedure typeAre you being treated for any other health issue(s) not mentioned above? *YESNOProvide detailsDo you engage in any airborne sport, motor-powered racing vehicles, rock climbing, scuba diving, etc.? *YESNOProvide detailsDo you intend to travel outside the U.S. in the next 2 years? *YESNOWhat country?Please list moving vehicle violations over the last 5 years: *Have you had covid? *YESNOApproximate date:Have you fully recovered from Covid? *YESNODid Covid treatment require oxygen, hospitalization, ICU admission, or ventilation? *YESNONeck or back disorders *YESNOMemory problems *YESNODiabetes *YESNOPlease provide below date of diagnosis and current treatment detailsCancer *YESNOPlease provide below date of diagnosis/stage of tumor/current and past treatmentsStroke or TIA (mini stroke) *YESNOJoint issues, including cortisone shots to relieve pain in joints *YESNOOsteoporosis *YESNOAsthma *YESNOSleep Apnea *YESNOAIDS/HIV or other immune system disorder *YESNOMacular degeneration, glaucoma, or other eye disease *YESNOPast or current alcoholism or drug abuse *YESNOAny blood-related diseases *YESNODepression, anxiety, or other psychiatric disorder *YESNOArrhythmia *YESNOAtrial fibrillation *YESNOPacemaker *YESNOHeart conditions *YESNOAngioplasty or other procedure *YESNOMultiple sclerosis *YESNOHigh blood pressure or high cholesterol *YESNOLou Gehrig's Disease *YESNOLupus *YESNOParkinson's disease *YESNOEpilepsy or seizures *YESNONeuropathy (in relation to diabetes) *YESNOKidney problems *YESNOLung or respiratory disorder *YESNOArthritis (please describe) *YESNOFibromyalgia *YESNOChronic pain condition *YESNOProblems with balance *YESNOChronic fatigue *YESNOSubmit