Preliminary Medical History Form

Proposed Insured Information

First Name

Middle Initial

Last Name

Date of Birth

U.S. Citizen?

YesNo

Physician Information

Name and address of proposed insured's physicians. If none, write "None."

Physician name, date, reason, findings and treatment at last visit. If none, write "None".

Height and Weight

Height (feet)

Height (inches)

Weight (lbs)

Has proposed insured had any weight change in excess of 10 lbs. in the past year?

YesNo

Gain or loss?

GainLoss

Amount (lbs)

Reason for weight change

Has proposed insured used any of the following tobacco or nicotine products in the last 5 years? (Check all that apply)

Frequency of cigarette use:

Date of last cigarette use:

Frequency of cigar use:

Date of last cigar use:

Frequency of pipe use:

Date of last pipe use:

Frequency of chewing tobacco use:

Date of last chewing tobacco use:

Frequency of nicotine vape use:

Date of last nicotine vape use:

Frequency of non-vape nicotine use:

Date of last non-vape nicotine use:

Additional questions will generate upon submission of this form

Please explain

Has proposed insured used cocaine, marijuana, heroin, controlled substances or any other drug, except as legally prescribed by a physician?

YesNo

Please explain

Had any laboratory tests, treatments/diagnostic procedures, including x-rays, scans or EKGs?

YesNo

Please explain

Been advised to have any diagnostic test, hospitalization or treatment that was not completed?

YesNo

Please explain

Received or claimed disability or hospital indemnity benefits or a pension for injury, sickness, disability or impaired condition?

YesNo

Please explain

Cigarettes	Cigars	Pipe
Chewing tobacco	Nicotine vape	Non-vape nicotine product (gum, pouch, patch)