Filter Type:

DIABETES

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CONTACT INFORMATION

Name:

Email Address:

Telephone Number (optional):

State of Residence:

Please contact by:

Email Phone

PERSONAL INFORMATION

Male Female

Date of Birth:

Height:

Weight:

Do You Use ANY tobacco products:

No Yes

If "yes" please indicate what type:

TYPE OF COVERAGE DESIRED

Term Insurance Permanent Life (Cash Value)

Coverage Amount: $

Term Life and Permanent Life Explained

MEDICAL BACKGROUND

Type of Diabetes:

Insulin

Oral Meds

Diet Controlled

Gestational

Age of onset:

Type of medication(s) and dosage:

Ever hospitalized for diabetes?

Yes No

If "yes", when:

How long?

When were you last seen by your doctor:

How often do you visit your doctor:

Do you have Glycohemoglobin (A1C) tests done?

Yes No

Please enter latest results:

Do you test your own blood sugar?

Yes No

What is the average?

Date of last blood sugar test:

Results:

Are you and your doctor pleased with the results and control?

Yes No

Any protein in urine?

Yes No

If "yes" please give details:

Any eye problems?

Yes No

If "yes" please give details:

Any high blood pressure?

Yes No

If "yes" please give BP readings & Medications(s):

Please indicate cholesterol level, if known:

Have you ever had:

Heart Attack Stroke Bypass Surgery Stent Other Cardiac condition

If "yes" enter approximate date:

In the past 2 years, have you submitted an application for life insurance or health insurance and had that application declined?

Yes No

Are you currently receiving disability benefits, or in the past 6 months have you received disability benefits?

Yes No

Any other health concerns or comments (please list ALL medications here)?

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