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Medical Occupation Information

Personal Information Needed To Create Quotes

Which quotes have you seen already? *
About the applicant *
Income history
 2018 Current YTD20172016
What was your income in...
General Risk Questions *
---Medical Questions--- Have you EVER been diagnosed or treated by a licensed member of the medical profession for: *
 YesNoN/A
a. Any disease or impairment of the heart; arteries or veins; chest pains; high blood pressure (Hypertension) or low blood pressure (Hypotension)?
b. Arthritis; any disease, disorder or deformity of the bones, muscles, tendons, or joints, including the spine; any neck or back problems or impairments; carpal tunnel syndrome; any autoimmune diseases such as lupus or scleroderma, myofascial pain syndrome, complex regional pain syndrome or reflex sympathetic dystrophy syndrome?
c. Any mental, nervous or emotional problem, condition or impairment, including anxiety, depression, insomnia, stress or post traumatic stress disorder?
d. Stroke, embolism, or thrombosis?
e. Cancer, tumor or polyp?
f. Diabetes, high blood sugar or low blood sugar (hypoglycemia)?
g. Any disease or impairment of the lungs or respiratory system, asthma, allergy, emphysema, chronic obstructive pulmonary disease or sleep apnea?
h. Any disease or disorder of the liver, gall bladder, pancreas, digestive tract, including intestines; ulcerative colitis, Crohn’s disease or hernia?
i. Memory loss, loss of concentration, fatigue, neurological impairment, unconsciousness, loss of cognition, dizziness, paralysis or numbness, impairment of nervous system, epilepsy, seizures, migraine headaches, restless leg syndrome, polio, post polio syndrome or multiple sclerosis?
j. Any disease or impairment of the urinary tract or kidney; sugar, albumin or blood in urine?
k. Any physical deformity or physical impairment?
l. Any disease or impairment of the skin?
m. Any disease or impairment of glands; anemia, leukemia, bleeding or clotting impairment or other blood impairment?
n. Any disease or impairment of the prostate or testes; uterus, ovaries or breasts; pre-term labor or infertility?
o. Any disease or disorder or impairment of the eyes, ears, mouth, nose or throat; any decrease of vision or hearing?
p. Endocrine impairment or goiter or disease or impairment of the thyroid gland?
q. Any sexually transmitted disease?
r. Attention deficit disorder, attention deficit hyperactivity disorder, Alzheimer's disease, chronic fatigue syndrome, Epstein-Barr virus, fibromyalgia, lyme disease, myalgia or encephalitis
Have you EVER: been tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?
Other than as indicated previously, have you EVER: a. Had any medical test or surgical operation performed (including Caesarean-section) or gone to a hospital, doctor’s office, or other medical facility for observation, examination or treatment or been advised by a licensed practitioner acting within the scope of his/her license to have any medical test or surgical operation that was not performed?
b. Been advised by a licensed practitioner acting within the scope of his/her license to modify or restrict eating, drinking, or living habits because of any health condition?
c. Received medical treatment or advice by a licensed practitioner acting within the scope of his/her license for muscle weakness, unexplained weight loss of 10 pounds or more, swollen glands, visual disturbance, recurring diarrhea, fever or infection?
Are you pregnant? If YES, expected delivery Date in comments sections?
Within the last 5 years, have you taken, been advised to take or are you currently taking any prescription or nonprescription medications or over the counter herbal medications or supplements?
Have you EVER used cocaine, heroin or any other illicit drugs or controlled substances except as prescribed by a health care professional; received treatment or advice regarding the use of alcohol or drugs from a health professional or organization which assists those who have an alcohol or drug problem?

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