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Medical History Form

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Medical History

Please list all drugs prescribed or taken in the last 12 months

Applicant	Rx/Med & Mg	Reason	Doctor

General Information 1. Within the past two years, has any person to be insured used tobacco products, including cigarettes, cigars, or chewing tobacco?
Yes No
2. Has any person proposed for insurance had surgery within the last 5 years?
Yes No
3. To the best of your knowledge and belief, within the last 12 months, has any person to be insured, received treatment or had tests performed where the results were other than normal or still pending or received treatment for any abnormal tests?
Yes No
4. Has any person had surgery advised but not yet performed?
Yes No
5. To the best of your knowledge and belief, within the last 12 months, has any person to be insured had elevated or rising PSA/CEA test, abnormal mammogram, abnormal pap smear, or abnormal biopsy?
Yes No
6. Is any person to be insured currently hospitalized or scheduled for hospitalization in the next 12 months?
Yes No
7. Has any person to be insured ever been diagnosed with or treated for HIV/AIDS or other sexually transmitted diseases in the past 5 years?
Yes No
8. Has any person to be insured ever been diagnosed with or treated for HIV/AIDS or other sexually transmitted diseases in the past 5 years?
Yes No
9. Within the past five years has any person proposed for insurance been diagnosed with, received treatment for, or been prescribed medication for any of the following conditions?

a. Alcoholism, Alcohol, Chemical Dependency, or Drug or Alcohol Abuse
b. Autism Spectrum Disorders, Autism, Asperger’s Disorder, Rett’s Syndrome, Pervasive Developmental disorders, or Pervasive Developmental Delay
c. Heart Disorder, Heart Disease, Heart Attack, Coronary Bypass
d. Peripheral Vascular Disease or Peripheral Arterial Disease
e. Diabetes (Insulin controlled)
e. Crohn’s Disease or Ulcerative Colitis
f. Lupus
g. Osteomyelitis
h. Paralysis
i. Rheumatoid Arthritis
j. Sickle cell anemia
k. Stroke, TIA, or Brain Aneurysm
l. Tuberculosis (TB)
m. None of the above.

10. Is/are any proposed insured(s) now pregnant?
Yes No

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