Health Questionnaire

Brad Humpheries, CFP, ChFC, CLU, CLTC

bhumphries@colonialtrust.com

803-782-7647

Health Questionnaire

Pre-Screening for coverage options
Today's Date
Have you had any weight change in the past 12 months? *

Gained 10+ lbs Lost 10 + lbs No
Specify how much weight gained / lost
List medication you have taken or been prescribed in the last 12 months and the conditions for which they are being taken.
Enter Immediate Family Members Health Information (Both Parents and Siblings) *
In the last 5 years, have you been diagnosed, treated or consulted with a member of the medical profession for any of the following ? (select all the apply to you) *

High Blood Presure High Cholesterol Coronary Artery Disease Heart Attack Cardiac Chest Pain Arrhythmia/Irregular Heart Beat Heart Murmur/Valvular Hear Disease heart Failure Peripheral Vascular Diesease Stroke/Transient Ischemic Attack (TIA) Other Disorders of the Heart of Blood Vessels Diabetes High Blood Sugar/Glucose Intolerance/Pre-Diabetes Disorders of the Thyroid or Other Glands Cancer Leukemia / Lymphoma Benign Tumor / Polyp Anemia/Blood Disorder Auto Immune Disorder Asthma Emphysema/COPD/Chronic Bronchitis Sleep Apnea Other Respiratory/Lung Disorders Seizures/Epilepsy Tremors Paralysis Parkinson's Disease Multiple Sclerosos Cognitive Impairment / Memory Loss Alzheimer's Disease / Dementia Other Nervous System or Neurological Disorders Depression Anxiety Bipolar Disorder Other Psychological or Mental Health Disorders Ulchers Hepatitis Cirrhosis Crohn's / Ulcerative Colitis Barrett's Esophagus Other Disorders of the Liver, Gallbladder, Esophagus, Pancreas, Stomach, or Intestines Rheumatoid / Psoriasis Arthritis Fibromyalgia Osteoarthritis Osteoporosis Fractures Amputations Other Bone, Joint, Muscle or Connective Tissue Disorders Kidney Disease Disorders of the Bladder or Urinary Tract Disorders of the Prostate Disorders of the Breast Disorders of the Reproductive Organs None of these Apply to Me
If you elected any of the medical conditions listed above please provide: Condition / Name / Diagnosis - date of onset - Treatment given - duration of condition - Name, address, phone of physician and hospital *
In the past 10 years have you been advised to limit or discontinue alcohol use, or sought or received counseling or treatment by a member of the medical profession for alcohol use? *
In the past 10 years have you used, or tested positive by a member of the medical profession for Cocaine, Heroin, Amphetamines, or hallucinogens? *
In the past 10 years have you used, or tested positive by a member of the medical profession for Tranquilizers sedatives, or narcotic drugs or any prescription drug except those used in accordance with physician's instructions ? *
In the past 10 years have you sought or received treatment by a medical professional, counseling or participated in a support group for drug use? *
Are you insured on any other existing Life Insurance policies, including any policy that has been sold, assigned, transferred or settled? *
If Yes, please complete information below
*
Have you used Marijuana in the past 5 years? *
Do you use Tobacco/Nicotine products? (Products including, but not limited to cigarettes, e-cigs, cigars, pipe, chewing tobacco, snuff, hookah, nicotine patch, nicotine gum) NOTE: Tobacco use does not automatically nor necessarily result in deial of coverage. *
Do you exercise? (walking, running, treadmill, swimming, aerobics. strength training, cycling, sports or yoga, etc.) *
Have you ever had an application for life insurance declined, postponed, rated substandard, modified, required extra premium, or offered less than applied for by any company? Explain below *
In the past 12 months, have you missed more than 10 consecutive days of work, school, or daily/regular activities because of illness, injury, or medical treatment? Explain below *
Do you expect to travel outside the US or Canada, or change your country of residence in the next two years? If, yes explain below the details of location (city/country) purpose, frequency and duration. *
Have you ever flown or intend to fly in the next two years as a student pilot, or crew member in any aircraft, including ultra light planes? If yes, explain below *
Indicate any of the following activities you participate in or have participated in , within the last 2 years: *

Motorcycle racing Mountain climbing Scuba Diving Ballooning Heli skiing Power boat racing Hang-gliding Motor vehicle racing Bungee/base jumping Skydiving/Parachuting Backcountry skiing/snowmobilling I do not participate in any of these activites
Select all that apply to your driving history *

Convicted of 1 or more moving violations in the past 2 years License is currently revoked or suspended Convicted of drving while intoxicated otherwise impaired None of these apply to me
Have you been convicted of, plead guilty for, or are you currently awaiting trail for any infraction, misdemeanor, or felony? *

Yes (explain below) No
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