What Type Of Questions Will They Ask When I Take a Medical Exam For Life Insurance?

1.
Are you or any of your dependents currently pregnant? Y N
If yes, who? ___________________________
Expected due date: _____________________

2.
Do you or any of your dependents smoke or use tobacco? Y N
If yes, who? __________________________
Type? _______________________________

3.
In the past 10 years, has anyone ever:
a.
had high blood pressure or high cholesterol? If yes, last three readings:
________ _________ _________
b.
had heart disease, cancer, diabetes, arthritis, or asthma? Y N
c.
had counseling by a medical or social practitioner for an emotional, mental or nervous condition? Y N
d.
been treated for alcohol or chemical dependency, or been convicted for driving while intoxicated? Y N

4.
Has anyone ever been diagnosed by, or received treatment from, a member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex ARC)? Y N

5. In the past three years has anyone been prescribed medication? Y N

6. In the past 10 years has anyone had an inpatient admission and/or outpatient surgery? Y N

7.
During the past three years, has anyone sought medical treatment, or been advised by a medical or social practitioner to seek treatment for any condition not indicated by your answers to the preceding six questions? Y N

8.
Has anyone ever been rated or declined for, or refused reinstatement or renewal of, life or health insurance? Y N
If yes. name of person, date and reason:
______________________________________
______________________________________

9.
In the past three years, has anyone been engaged in or does anyone contemplate being engaged in sports or hobbies such as aviation, scuba diving, sky diving, racing, or similar activities? Y N

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