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Client Information
	Name		*
	Address
	City, State, Zip		*
	Home		*
	Work
	Cell
	Fax
	Email		*
	Date of birth		mm    dd   yy
	Sex		M    F
General Purpose Questionnaire
Client Information
	Date of birth		mm    dd   yy *
	Sex		M    F  *
	Height		Feet 2 ' 3 ' 4 ' 5 ' 6 ' 7 ' 8 ' 9 '   Inches 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"   *
	Weight (lbs.)		*
	Smoker		Yes    No  *
	Insurance amount
	Insurance type		Select one Term UL Survivor UL
	Additional insured's name (only if applying for Survivor UL)
Other company(s) actions
	Date applied		mm   yy
	Company
	Declined
	Postponed
	Rated table
1. What is illness?
	please provide details
2. When was diagnosis made?
	mm   yy
3. What type of treatment has been received?
	surgery month/year
	medication (list)
	other types of treatment
4. When was last visit to a physician about this disorder?
	select one 0-6 months 6-12 months 12-24 months more than 24 months ago
5. Date and result of last cholesterol reading.
	mm   yy
6. Date and result of last blood pressure reading.
	mm   yy
7. How many times per week does client exercise?
	select one None 1 time per week 2 times per week 3 times per week 4 times per week 5 times per week 6 times per week 7 times per week More than 7
	Type of exercise
8. Are there any other illnesses/impairments?
9. What medication is currently being taken?
10. Has either parent, or any sibling, died before age 65, other than by accident?
	Yes No  (If yes, list relationship(s) and cause)
	Relationship father mother sister brother    cause
	Relationship father mother sister brother    cause
	Relationship father mother sister brother    cause
Additional Information