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SkipToImpairmentQs

Yes

Proposed insured's name

Date of Birth

Gender at Birth

MaleFemale

Height (feet)

Height (inches)

Weight

lbs

Have you ever used any tobacco or nicotine products?

YesNo

Tobacco usage details

When did you last use tobacco or nicotine products?

What type tobacco or nicotine product?

How much/many per month?

Proposed insured's impairments (Check all that apply)

Arthritis	Atrial Fibrillation	Diabetes
Sleep Apnea	Alcohol	Abnormal Liver Test(s)
Anxiety/Depression	Coronary Bypass/Stent	Crohn's Disease/Ulcerative Colitis/Diverticulitis
Breast Cancer	Prostate Cancer	Bladder Cancer

Producing agent's name

Agent's MVP Contact

Alcohol

Does client presently consume alcoholic beverages? (Check all that apply)

BeerWineLiquorOther

Other; please provide details (number of drinks per day, week or month)

Beer

Number of drinks

drinks

Frequency

DailyWeeklyMonthly

Wine

Number of drinks

drinks

Frequency

DailyWeeklyMonthly

Liquor

Number of drinks

drinks

Frequency

DailyWeeklyMonthly

Have you been diagnosed with an alcohol use disorder, been hospitalized or went to a treatment facility, or been recommended to reduce alcohol by your physician?

YesNo

Please provide details including date of initial treatment or diagnosis

Have you had abnormal liver function test(s)?

YesNo

Have you had any alcohol-related legal problems (such as DUI) or other?

YesNo

Please provide details and dates of legal problems

Were there any relapses from sobriety/abstinence?

YesNo

Please provide details and dates of relapses from sobriety/abstinence

Have there been physical complications or additional psychiatric problems?

YesNo

Please provide details and dates, including use of other substances such as marijuana or cocaine

Do you currently participate in a group such as Alcoholics Anonymous

YesNo

Relevant medications currently being used or stopped within the last 12 months

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Liver Tests

How long has this abnormality (elevated liver enzymes) been present?

Please give the results of the most recent liver enzyme tests

AST (SGOT) Reading

Reading Date

Have these results been

IncreasingDecreasingFluctuating up and downStableUnknown

ALT (SGPT) Reading

Reading Date

Have these results been

IncreasingDecreasingFluctuating up and downStableUnknown

GGTP Reading

Reading Date

Have these results been

IncreasingDecreasingFluctuating up and downStableUnknown

ALP Reading

Reading Date

Have these results been

IncreasingDecreasingFluctuating up and downStableUnknown

Billirubin Reading

Reading Date

Have these results been

IncreasingDecreasingFluctuating up and downStableUnknown

Do you drink alcohol?

YesNo

Please note alcohol intake amount and frequency

Relevant medications currently being used or stopped within the last 12 months

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Anxiety/Depression

See questions for...

Anxiety DisorderDepression

Anxiety Disorder

Date of diagnosis

What specific type of anxiety disorder has been diagnosed? (check all that apply):

Generalized anxiety disorder	Panic disorder
Obsessive compulsive disorder	Post-traumatic stress syndrome
Agoraphobia	Other anxiety disorder

Other; please specify

Have you been hospitalized for the treatment of anxiety disorders?

YesNo

Please list dates of hospitalization (mm/dd/yyyy format) and length of stay

Medications currently being used for anxiety disorder or stopped within the last 12 months:

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Depression

Date of diagnosis

Please list the dates of any subsequent depressive episodes (mm/dd/yyyy format)

What specific type of depression has been diagnosed? (check all that apply):

Bipolar Disorder (mixed)	Bipolar Disorder (manic)
Bipolar Disorder (depressed)	Dysthymia
Major Depression	Other

Other; please specify

Have you been hospitalized for the treatment of depression?

YesNo

Please list dates of hospitalization (mm/dd/yyyy format) and length of stay

Relevant Medications currently being used or stopped within the last 12 months:

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

General Information

Does client have a history of any of the following associated conditions? Please check all that apply.

Personality disorder	Psychotic disorder
Suicidal thought/attempt	Alcohol abuse
Other substance abuse (drugs)	Other psychiatric disorder

Other; please specify

Are you currently working? If yes, please list occupation:

YesNo

Occupation

Has any time been lost from work as a result of the condition(s)?

YesNo

Please give full details

Coronary Bypass/Stents

See questions for...

Coronary BypassStents

Coronary Bypass

Date of diagnosis

Type of coronary artery disease

Please provide the following details related to the bypass: Number of vessels bypassed, Percentage occlusion of vessels, Date(s) of procedure (format mm/dd/yyyy)

Have you had any chest discomfort since the procedure?

YesNo

Please explain the chest discomfort:

The following tests have been completed since procedure (check all that apply):

Regular EKGStress EKGEchoStress Echo

Regular EKG information

Date of regular EKG

Were the results of your regular EKG normal or abnormal?

NormalAbnormal

Please explain abnormal EKG results:

Stress EKG information

Date of stress EKG

Were the results of your stress EKG normal or abnormal?

NormalAbnormal

Please explain abnormal stress EKG results:

Echo information

Date of echo test

Were the results of your echo test normal or abnormal?

NormalAbnormal

Please explain abnormal echo test results:

Stress Echo information

Date of stress echo

Were the results of your stress echo normal or abnormal?

NormalAbnormal

Please explain abnormal stress echo results:

Relevant medications currently being used or stopped within the last 12 months:

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Stents

Which arteries were affected, and what was the percentage of blockage for each? Please include the date(s) of each stent placement (mm/dd/yyyy)

LAD, for example, is totally different than RCA

What event or condition led to the placement of the stent? Please provide as much detail as possible.

Please describe your symptoms before and after the placement:

If you know, what is your heart's current/most recent Ejection Fraction?

Are you currently exercising regularly?

YesNo

Did you have cardiac rehab?

YesNo

What is your smoking status?

NeverQuit before stent placement(s)Quit after stent placement(s)Currently a smoker

Relevant medications currently being used or stopped within the last 12 months:

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Have you had any of the following conditions or lifestyle factors?

Heart attackHeart failureCoronary angioplasty (PTCA)Valve surgeryAbnormal lipid levelsElevated homocysteineOverweightPeripheral vascular diseaseCerebrovascular diseaseCarotid disease

Colitis and Crohn's Disease Questionnaire

Which condition has been diagnosed?

Irritable bowel syndrome Mucous colitisChronic proctitis (rectum)Frequent colon spasmsSpastic colitisChronic ulcerative colitisFrequent diarrheaCatarrhal colitisCrohn's diseaseUlcerative proctitisUlcerative proctosigmoiditisOtherIf more than one of these conditions applies, click "Add another condition" at the bottom of this page

Date of first diagnosis

Date of most recent episode

Total number of episodes

Number of episodes in past six months

Longest duration in past six months (days, weeks, months)

Number of episodes in past five years

Longest duration in past five years (days, weeks, months)

Have you ever been hospitalized for the condition?

YesNo

Please list hospitalization dates (mm/dd/yyyy)

Has surgery been recommended?

YesNo

Please share details, including when the surgery will be completed

Has surgery been done?

YesNo

Please list type of surgery/surgeries and date(s) (mm/dd/yyyy)

Have you ever been disabled because of the condition?

YesNo

Please list date(s) (mm/dd/yyyy)

Are you taking any medications for this condition?

YesNo

Relevant medications currently being used or stopped within the last 12 months:

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another medication to list, click "Add another medication" below

If more than one condition applies, click "Add another condition" above

Cancer

What type of cancer was diagnosed?

Date of first diagnosis:

How was the cancer treated? (Check all that apply)

Endoscopic resection only	Endoscopic resection and chemotherapy instilled in the bladder
Radical cystectomy (removal of the bladder)	Radiation therapy
Systemic chemotherapy

What stage was the cancer?

Stage 0 - In-situ	Stage I	Stage II
Stage IIIA	Stage IIIB	Stage IV

Has there been any evidence of recurrence?

YesNo

Please give details regarding evidence of recurrence

Results of last cystoscopy:

Date of last cystoscopy:

Results of last urine cytology:

Date of last urine cytology:

Relevant medications currently being used or stopped within the last 12 months

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Breast Cancer

Date of diagnosis:

Exact name of the type of breast cancer that has been diagnosed

What stage was the cancer?

Stage 0 - Ductile carcinoma in-situ	Stage 0 - Lobular carcinoma in-situ
Stage 0 - Paget's disease of nipple	Stage I
Stage II	Stage IIIA
Stage IIIB	Stage IV

If the cancer was graded, what grade was assigned?

Grade IGrade IIGrade IIIGrade IV

How was the cancer treated? (Check all that apply)

Excisional biopsy	Lumpectomy or wide excision
Partial mastectomy	Modified radical mastectomy
Radical mastectomy	Radiation therapy
Chemotherapy	Hormone therapy
Bone marrow transplant

Date treatment was completed:

Were lymph nodes involved?

YesNo

How many lymph nodes were involved?

Hormone receptor status

PositiveNegative

Size of tumor

Has there been any evidence of recurrence?

YesNo

Please give details regarding evidence of recurrence

Results of last mammogram:

Date of last mammogram:

Relevant medications currently being used or stopped within the last 12 months

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Bladder Cancer

Date of diagnosis:

How was the cancer treated? (Check all that apply)

Endoscopic resection only	Endoscopic resection and chemotherapy instilled in the bladder
Radical cystectomy (removal of the bladder)	Radiation therapy
Systemic chemotherapy

What stage was the cancer?

Stage 0 - In-situ	Stage I	Stage II
Stage IIIA	Stage IIIB	Stage IV

Has there been any evidence of recurrence?

YesNo

Please give details regarding evidence of recurrence

Results of last cystoscopy:

Date of last cystoscopy:

Results of last urine cytology:

Date of last urine cytology:

Relevant medications currently being used or stopped within the last 12 months

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Prostate Cancer

Date of diagnoses:

What was the pretreatment PSA?

How was the cancer treated? (check all that apply)

Observation only	TURP (transurethral prostatectomy)
Radical prostatectomy	Radiation therapy (seed implant or external beam radiation)

Result of most recent PSA test:

Date of most recent PSA test:

What was the Gleason score?

What stage was the cancer?

Stage 0 (in-situ)Stage IStage IIStage IIIStage IV

Is there a family history of cancer?

YesNo

Relevant medications currently being used or stopped within the last 12 months

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Arthritis

Date first diagnosed with arthritis:

What type of arthritis is it? (Example: rheumatoid, osteo, gouty, etc.)

Are the joints involved?

YesNo

What is the type of treatment?

Does treatment include cortisone?

YesNo

Medications currently being used or stopped within the last 12 months

Name of medication

(Please use accurate name)

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Atrial Fibrillation

Date first diagnosed:

Is the atrial fibrillation/flutter chronic (permanent) or paroxysmal (intermittent)

Chronic (permanent)Paroxysmal (intermittent)

Symptoms (check all that apply)

Black-out(s)Dizziness (lightheadedness/faint feeling)PalpitationsChest discomfort

Have any of the following tests been done?

ECGStress testEchocardiogramHolter monitor

Most recent ECG date

Most recent ECG results

Most recent stress test date

Most recent stress test results

Most recent echocardiogram date

Most recent echocardiogram results

Most recent Holter monitor use date

Most recent Holter monitor results

The cause of the atrial fibrillation/flutter is due to:

Coronary heart disease	Thyroid disease	Mitral valve disease	Alcohol
Cardiomyopathy	Unknown	Other cause(s) not listed here

Other cause(s) not listed above; please give details

Medications currently being used or stopped within the last 12 months

Name of medication

(Please use accurate name)

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Diabetes

Date first diagnosed with diabetes:

Diabetes Type

Your diabetes is controlled by:

Diet and exerciseOral medicationInsulin

Oral diabetes medication and dosage:

Insulin amount and units/day:

Most recent hemoglobin A1c level:

Date of A1c reading:

Please check if you have or have had any of the following:

Chest pain or coronary artery disease	Protein in the urine	Elevated lipids
Weight problems	Neuropathy	Kidney disease
Retinopathy	Abnormal ECG	Hypertension
Albuminuria	Glycosuria	Diabetic coma
Alcohol/drug abuse

Other medications currently being used or stopped within the last 12 months

Name of medication

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Sleep Apnea

Date of sleep apnea diagnosis

Was the sleep apnea diagnosed as:

ObstructiveCentralMixedUnknown

Are you currently using a CPAP mask for treatment?

YesNo

Have you ever been given a CPAP mask for treatment?

YesNo, but doctor did recommendNo, doctor never recommended

Did you terminate CPAP use with knowledge and agreement of your doctor?

YesNo

Date previous CPAP use was terminated

Reason previous CPAP use was terminated

Reason you did not use CPAP despite doctor's recommendation:

Have you remained compliant with doctor's recommended CPAP mask protocol? (e.g. nightly use)

YesNo

Reason you did not remain compliant with doctor's recommended CPAP mask protocol:

How else is sleep apnea being treated?

ObservationWeight lossSurgeryOther

You selected 'other' treatment; please give details

Type of surgery

Date of surgery

Did surgery correct sleep apnea?

YesNo

Surgery details:

Have you had any of the following?

lung disease	obesity	chest pain or coronary artery disease
depression	stroke	arrhythmia

Medications currently being used or stopped within the last 12 months:

Name of medication

(Please use accurate name)

Dosage

Did you stop this medication in the last 12 months?

Yes, per doctor's knowledge and agreementYes, without doctor's agreementNo

Do you have any additional comments on the usage of this medication?

If you have another, click "Add another medication" below

Additional health issues/information

Please list current medications, other info, and/or any other conditions not already mentioned:

e.g. high cholesterol, blood pressure, etc.

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