Pulmonary/ Lung Disease Questionnaire
Asthma, Chronic Bronchitis, COPD, Emphysema, Restrictive Lung Disease
| Fax to:
UNDERWRITING SOLUTIONS Tel.: (760) 435-9702 Fax: (760) 435-9703 Email: UndSolutions@cs.com |
| NAME __________________ [] Male [ ] Female Age ____ Date of Birth __________ |
| Tobacco use: [ ] No [ ] Cigarettes [ ] Other tobacco ___ Date quit? _______ [ ] Never smoked |
| STATE ______ Amount of Insurance ____________ Type of Insurance ___________ |
| Occupation/ Source of Income: __________________________ |
| 1.
Type of lung disease?
[ ] Asthma - Date diagnosed: ____________ [ ] Chronic Bronchitis (COPD) - Date diagnosed: ____________ [ ] Emphysema - Date diagnosed: ____________ [ ] Restrictive lung disease - Date diagnosed: ____________ 2. Have you been hospitalized for a lung disease? [ ] No [ ] Yes: Details: ____________________________________________________________________ 3. What were your last pulmonary function test results? [ ] None performed [ ] Last pulmonary function test results - Date: _____ FVC% _____ FEV1% _____ 4. Have you had any abnormalities on: [ ] chest x-ray [ ] EKG [ ] Stress EKG? Details: ____________________________________________________________ 5. Current medications (including inhalers) or treatments for lung condition?
|
| General Questions |
| 1. Do you have any other major health problems? [ ] No [ ] Yes - Details: _________________________________________________________________________________ |
| 2. List all other medication used? ____________________________________________________ |
| 3. Height _______ Weight _______ Weight loss in past year? [ ] No [ ] Yes _____ lbs. Most recent blood pressure reading: ______________ |
| AGENT NAME: ___________________________________________ |
| ADDRESS: _______________________ CITY: _____________ STATE: _____ ZIP: ________ |
| PHONE: ________________ FAX: _________________ Email: ____________________ |
The information gathered above will be used in the evaluation of the insurability of the applicant. All offers are tentative and are subject to verification of the submitted medical evidence and other criteria used in the underwriting of life insurance. Copyright 2000 to 2003 by Fredric Berger. All rights reserved.