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+ lbsLost 10 + lbsNoOther
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 PresureHigh CholesterolCoronary Artery DiseaseHeart AttackCardiac Chest PainArrhythmia/Irregular Heart BeatHeart Murmur/Valvular Hear Diseaseheart FailurePeripheral Vascular DieseaseStroke/Transient Ischemic Attack (TIA)Other Disorders of the Heart of Blood VesselsDiabetesHigh Blood Sugar/Glucose Intolerance/Pre-DiabetesDisorders of the Thyroid or Other GlandsCancerLeukemia / LymphomaBenign Tumor / PolypAnemia/Blood DisorderAuto Immune DisorderAsthmaEmphysema/COPD/Chronic BronchitisSleep ApneaOther Respiratory/Lung DisordersSeizures/EpilepsyTremorsParalysisParkinson's DiseaseMultiple SclerososCognitive Impairment / Memory LossAlzheimer's Disease / DementiaOther Nervous System or Neurological DisordersDepressionAnxietyBipolar DisorderOther Psychological or Mental Health DisordersUlchersHepatitisCirrhosisCrohn's / Ulcerative ColitisBarrett's EsophagusOther Disorders of the Liver, Gallbladder, Esophagus, Pancreas, Stomach, or IntestinesRheumatoid / Psoriasis ArthritisFibromyalgiaOsteoarthritisOsteoporosisFracturesAmputationsOther Bone, Joint, Muscle or Connective Tissue DisordersKidney DiseaseDisorders of the Bladder or Urinary TractDisorders of the ProstateDisorders of the BreastDisorders of the Reproductive OrgansNone of these Apply to MeOther
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 racingMountain climbingScuba DivingBallooningHeli skiingPower boat racingHang-glidingMotor vehicle racingBungee/base jumpingSkydiving/ParachutingBackcountry skiing/snowmobillingI 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 yearsLicense is currently revoked or suspendedConvicted of drving while intoxicated otherwise impairedNone 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
Should be Empty: