IMPORTANT MESSAGE FOR RESIDENTS OF NEW YORK

Pursuant to New 11 NYCRR § 229.5(b) and 3 NYCRR § 405.6(b)(4)

LifeQuotes is giving you the below information and link to the State of New York Executive Order as follows:

New York Governor, Andrew M. Cuomo issued Executive Order 202.13 and the emergency adoption of 11 NYCRR 229 (INSURANCE REGULATION 216) INSURER PRACTICES DURING THE COVID 19 PANDEMIC by the New York State Department of Financial Services (DFS).

In order to assist policyholders impacted by the COVID 19 pandemic, Executive Order 202.13 and Regulation 216 requires insurers to take specific actions to alleviate the adverse impact caused by the pandemic on policyholders who can demonstrate financial hardship. Specifically, to extend to 90 days the grace period for the payment of premiums and fees, and for the exercise of rights, under life insurance policies and annuity contracts.

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Coverage Amount

How much coverage do I need?

If you are an employed family income breadwinner with minor children, financial planners suggest carrying a minimum of ten times your annual income. If you are a non-working caregiver at home with minor children, we suggest at least $150,000. If you are an adult looking for burial coverage only, we suggest $5,000 to $25,000.

Coverage Estimator Tool

ZIP Code

Health, financial and lifestyle items that can affect your life insurance rate

Birth Date (Ages 14 Days - 85 Years)

Gender

Male

Female

Height

feet inches

Weight with clothes on
Use higher of current or from last doctor visit
(OK to apply ½ of weight loss in last year)

Why does the life insurance company need to know your actual weight?

Weight (with clothes on) is a key rating factor with all life insurance companies. Please give an honest answer here so that you can receive accurate rate quotes. And keep in mind that the paramed examiner who visits you will be carrying a portable scale, so be honest here.

lbs.

Have you used any tobacco, nicotine, marijuana, vape, e-cigarette or tobacco substitute in the last 5 years?

Why do life insurers ask about this?

Nicotine use of any kind, as well as marijuana use, is looked at very closely by all life insurers. Smoking, chewing, inhaling in a vaporized form, consuming in edible products, or wearing a patch on the skin - all constitute use of these products. Non-admittance of marijuana use can result in a decline. Sources of information the insurer may use include: statements made on your application, telephone interviews, your paramed exam results (if one is required), your outside medical records and your Medical Information Bureau (MIB) profile. If you currently use marijuana AND any product containing tobacco or nicotine, please select the response that most closely describes your tobacco or nicotine use. Always be 100% honest when you answer tobacco use questions to ensure accurate quotes. Remember, a false statement on an application for insurance could void your coverage.

Yes

Indicate last tobacco, nicotine, marijuana, vape or tobacco substitute use:

Do you now (or have you in the last year) worked at a paying job (employed or self-employed) 20 or more hours per week?

Yes

Please check any of the following that apply to you:

I am receiving disability payments or government assistance such as food stamps, WIC or Medicaid

In the last 5 years, I had bad credit issues, overdue loans, bankruptcy, judgements, tax liens, collections or a debt repayment plan established

I am not a U.S. Citizen

I intend to travel to any country rated 3 or 4 on the U.S. State Department's Travel Advisory list

I participate in hazardous activities or occupations such as aviation, racing, scuba diving, skydiving, rock climbing, etc.

I have a criminal conviction history or law enforcement infractions

Within the last 5 years, I have received 3 or more moving violations or been convicted of driving while under the influence (DUI)

I have been rated up or declined for life insurance in the past

I have one or more parents or siblings who, prior to age 60, have been diagnosed with or died from cardiovascular, heart or coronary artery disease, stroke or cancer

I now have medical tests or procedures recommended that are not yet completed

I have taken prescription medications (including from a dentist) in the past 3 years or been diagnosed with a medical condition in the last 10 years

Are you now receiving disability payments from any source?

Yes

Check all that apply:

SSDI

Other Govt.

Private Insurance

For what illness or injury are you receiving disability payments?

Are you now receiving any form of government assistance such as food stamps, WIC or Medicaid?

Yes

Check all that apply:

Food Stamps

WIC

Medicaid

Other

Please explain:

Have you had a bankruptcy discharged or established a bankruptcy repayment plan in the last 12 months?

Yes

What type of immigrant visa do you have?

Please provide the purpose of your planned foreign travel, location(s) to be visited, and number of days expected in coming year.

Check the activity(ies) that you participate in:

Commercial Aviation

Mountaineering/Rock Climbing

Private Aviation

Scuba Diving

Motorized Racing

Other

Aviation Questionnaire

Do you fly as a pilot or crew member?

Total number of hours flown as a pilot

Do you have a valid FAA Medical Certificate?

Yes

Class of FAA Medical certificate held

Date of last FAA medical exam

Was the medical certificate issued under special issuance or with any restrictions?

Yes

Special issuance or restriction?

Special Issuance

Restriction

For what condition?

Do you have a valid FAA Airman Certificate?

Yes

What type:

Student

Sport

Recreational

Private

Commercial

Airline Transport

What class:

Airplane

Rotorcraft

Powered Lift

Glider

Lighter Than Air

Other

What rating:

Single Engine

Multi-Engine

Land

Sea

Instrument

Other

Do you have an Instrument Flight Rating?

Yes

Have you ever been in an aircraft accident, grounded, fined, reprimanded or had your license revoked?

Yes

Please Explain:

Date license was obtained:

What is the make and model of the primary aircraft that you currently fly?

Make Model

Are you a member of any branch of the military (including Reserves or National Guard)?

Yes

Branch of Service:

Last Flight in Service:

Type of aircraft in service:

How long have you flown this type of aircraft?

Ever fly into war zones?

Yes

Where?

Do you ever fly from an aircraft carrier?

Yes

Where?

Is all aviation activity conducted in the United States or Canada?

Yes

Please Explain:

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

List another type of flying as a pilot?

Yes

Type of flying as a pilot

Hours expected over next 12 months:

Please explain specifically what type of flying you engage in as a pilot:

Describe duties as a crew member aboard the aircraft:

What is the make and model of the primary aircraft that you are a crew member of?

Make Model

Flight time as crew member in hours:

Total to date Last 12 mos. Next 12 mos.

Scuba Diving Questions

Do you expect to make more than 10 dives in the next 12 months?

Yes

What is the maximum depth to which you will dive?

Are you a certified dive instructor or professional diver?

Yes

Do you participate in any technical or high risk dives, including but not limited to cave, ice, or salvage diving?

Yes

Please specify the type of climbing, years of experience, average heights, degree of difficulty, and other details related to your mountaineering and/or rock climbing.

Please specify the type of racing, years of experience, type of vehicle and track, and other details related to your motorized racing activities.

Please specify the exact type of activity and other details related to the potentially hazardous sport or activity in which you participate.

In what year was the criminal conviction or law enforcement infraction?

Please provide details of the conviction or infraction (charge(s), state, time served, etc.).

If you need to list a second incident, in what year did it occur?

Please provide details of the conviction or infraction (charge(s), state, time served, etc.).

In what year was the most recent moving violation?

Please provide details of the conviction or infraction (charge(s), state, time served, etc.).

If you need to list a second incident, in what year did it occur?

Please provide details of the conviction or infraction (charge(s), state, time served, etc.).

If you need to list a third incident, in what year did it occur?

Please provide details of the conviction or infraction (charge(s), state, time served, etc.).

If you need to list a fourth incident, in what year did it occur?

Please provide details of the conviction or infraction (charge(s), state, time served, etc.).

What was the name of the insurance company you were rated up or declined by?

What was the approximate date of your application?

Were you declined or rated up (approved for a higher premium than you applied for)?

What was the reason given for the decline or rate-up?

Has there been any incidence of cardiovascular, heart or coronary artery disease, or stroke in any parent or sibling prior to age 60?

Yes

Please check the applicable family member(s) and incidence(s):

• Cardiovascular diagnosis before age 60

Mother

Father

Sibling

• Cardiovascular death before age 60

Mother

Father

Sibling

Has there been any incidence of cancer, other than basal or squamous cell skin cancer, in any parent or sibling prior to age 60?

Yes

If you have multiple family members to list, start with any parent.

Which family member?

What was the type of cancer?

Did this family member pass away from the cancer?

Yes

List another familial cancer incidence?

Yes

Second Familial Cancer Incidence

Which family member?

What was the type of cancer?

Did this family member pass away from the cancer?

Yes

List another familial cancer incidence?

Yes

Third Familial Cancer Incidence

Which family member?

What was the type of cancer?

Did this family member pass away from the cancer?

Yes

List another familial cancer incidence?

Yes

Fourth Familial Cancer Incidence

Which family member?

What was the type of cancer?

Did this family member pass away from the cancer?

Yes

You've indicated that you have an outstanding medical test or procedure that is not yet completed. We'll show you quotes, but please click Yes to indicate your understanding that those tests will have to be completed before you apply for more than $30,000 of regular life insurance.

Yes

In the past 10 years, have you had or been treated for any of the following conditions?

Alcohol Abuse

Anxiety, ADD or ADHD

Asthma

Blood Pressure (Hypertension)

Cholesterol (Elevated)

Drug Abuse or Addiction

Gastric/Peptic Ulcers

Recurrent Kidney Stones

Do you recall your last blood pressure reading?

Systolic

Diastolic

Do you recall your last total cholesterol reading and cholesterol HDL ratio?

Total

Ratio

Alcohol Abuse Questionnaire

Year of diagnosis:

How long did the abuse continue?

Were there any relapses from sobriety/abstinence?

No Yes

Date:

Is there any current alcohol usage?

No Yes

Frequency and amount:

Date of last alcohol consumption:

Were there any legal problems (such as DUI or other)?

No Yes

Date:

Ever had any of the following occurrences or symptoms?

Elevated Liver Enzymes

Positive Alcohol Marker

If elevated liver enzymes, are current enzyme levels normal?

No Yes

Blackouts

Withdrawal Seizures

Alcohol Related Medical Complications

Family/Friends Concern Over Drinking Habits

Alcohol Related Medical Complications date and details:

Use Of Other Substances Such as Marijuana Or Cocaine

Other substances abused details:

Have there been any hospitalizations for this condition?

No Yes

Dates and details:

Do you currently participate in a group such as Alcoholics Anonymous?

No Yes

Has therapy been done for this condition?

No Yes

Details:

Are any medications being taken for this condition?

No Yes

Details:

Describe how well this condition is under control or if it restricts normal life in any way:

Asthma Questionnaire

Year of diagnosis:

Age when first diagnosed:

Describe frequency and symptoms:

Is there a trigger for attacks (e.g stress, allergies, exercise, etc.)?

No Yes

Details:

Are there any episodes within 5 years requiring ER visits or hospitalization?

No Yes

Details:

Has there been time lost at work or school due to this condition?

No Yes

Details:

Have you ever smoked?

No Yes

Date of last tobacco usage:

Including inhalers, are any medications being taken for this condition?

No Yes

Name of medication and frequency of use:

Have pulmonary function or other tests been done?

No Yes

Type of tests and results:

Do you have any abnormalities on an ECG or x-ray?

No Yes

Details:

Describe how well this condition is under control or if it restricts normal life in any way:

Drug Abuse Questionnaire

Year of diagnosis:
What types of drug(s) were used?
How often were the drugs used?
In what amount were the drugs used?
How long did the abuse last?
When was the date of last use?

Is there any history of drug overdose?

No Yes

Please list date(s):

Were there any relapses from sobriety/abstinence?

No Yes

Please list date(s):

Were there any legal problems (such as DUI or other)?

No Yes

Please give details including dates:

Have there been physical complications or additional psychiatric problems?

No Yes

Please give details:

Please list current medications:

Is there any current use of alcohol?

No Yes

Amount and frequency:

Was there participation in a drug rehabilitation program(s)?

No Yes

Date and name of program:

How long did the program last?

In-Patient

Out-Patient

Has there been or Is there any participation in recovery groups(such as Narcotics Anonymous)?

No Yes

Are you currently working part-time?

No Yes

Are you currently working full-time?

No Yes

Are you currently married?

No Yes

Describe how well this condition is under control or if it restricts normal life in any way:

Gastric/Peptic Ulcers Questionnaire

Year of diagnosis:

Please note how the ulcer was treated:

Medications only

Details:

Surgery only

Date and type of surgery:
Was repeat surgery required?

Both

Medications details:
Date and type of surgery:
Was repeat surgery required?

Have there been any recurrences or more than one episode?

No Yes

How many episodes?
Date, duration, and severity of attack:

Are you on any medications?

No Yes

Details:

Describe how well this condition is under control or if it restricts normal life in any way:

Recurrent Kidney Stones Questionnaire

Year of diagnosis:

Date of most recent attack:

How many episodes have you had?

How many total stones have there been?

Have you ever been hospitalized for this condition?

No Yes

Details:

Has any special testing been done, such as kidney function tests?

No Yes

Details:
Test results:

Please list the type of treatment received:

Describe how well this condition is under control or if it restricts normal life in any way:

For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?

Alzheimer's

Artery (Coronary) Disease

Arthritis (Psoriatic or Rheumatoid)

What type of Arthritis?

Psoriatic Arthritis

Rheumatoid Arthritis

Cancer

Colitis or Ileitis

COPD

What type of cancer?

Breast Cancer

Leukemia

Melanoma

Prostate Cancer

Skin Cancer

Other

Crohn's Disease

Depression or Mental Illness

Diabetes

Emphysema

Epilepsy

Fibromyalgia

Gout

Heart Disease or Abnormal EKG

Hepatitis or Liver Disease

HIV

Hypothyroidism (low thyroid)

Kidney Disease

Lupus

Mitral Valve Prolapse

Multiple Sclerosis

Pain (Chronic & Ongoing)

Parkinson's Disease

Prostate Issues (no cancer)

Sarcoidosis

Sleep Apnea

Stroke

Vascular Disease

Psoriatic or Rheumatoid Arthritis Questionnaire

Year of diagnosis:

Age at diagnosis:

Have you ever had any of the following occurrences or symptoms?

Weight Loss	Fever
Low Blood Counts	Heart Disease
Lung Disease	Liver Enzyme Abnormality
Kidney Disease	Other:

Which joints are involved?

Describe present symptoms:

List medications for this condition:

Have you ever taken steroids, gold, or immunosuppresive therapy?

No Yes

Type and date range:

Please check functional ability:

Fully Active	Sedentary
Uses Walker, Cane, etc.	Uses Wheelchair

Describe how well this condition is under control or if it restricts normal life in any way:

Vascular / Heart Disease or Abnormal EKG Questionnaire

List history of vascular or heart disease (i.e. what diagnosis?)

Year of diagnosis:

What was your age when diagnosed with this condition?

Ever had any of the following occurrences or symptoms?
Chest Pain	Trouble Breathing
Heart Failure	Heart Palpitations
Atrial Fibrillation/Flutter	Abnormal EKG
Enlarged Heart

Have you ever smoked?

No Yes

Date of last tobacco usage:

Have any of the following tests been done or recommended?

Echocardiogram

Were there any ST or T wave changes?

No Yes

Exercise Treadmill or Thallium

Date:

Stress Test

Date:
Results:

Other

Details:

Ever had any of the following procedures done or recommended?

Cardiac Catheterization

How many?
Date:

Coronary Angioplasty

How many?
Date:

Coronary Artery Bypass Graft

How many?
Date:

Coronary Defibrillator

Date:

Coronary Stent

How many?
Date:

Coronary Pacemaker

Date:

Valve Surgery

Which valve?
changes

Are you taking medications for the condition (including aspirin)?

No Yes

Details:

Medication Selector:

Are there any restrictions on daily activities?

No Yes

Details:

What is date and result of last checkup with any heart specialist for this condition?

Note: Underwriters typically require current (within last 24 months) cardiac follow-up on your part and compliance with your doctor's recommendations given that cardiac-related death is #1 cause of death in the U.S. All cardiac and cardiac-related medical records are looked at very closely by the life underwriter and compliance with your doctor's instructions and regular checkups are critical to getting a good life insurance offer.

Are you in compliance with your doctor's recommendations?

No Yes

Describe how well this condition is under control or if it restricts normal life in any way:

Breast Cancer Questionnaire

Year of diagnosis:

How was the cancer treated?

Removal of tumor only

Date completed:

Lumpectomy or wide excision

Date completed:

Mastectomy

Date completed:

Radiation therapy

Date completed:

Chemotherapy

Date completed:

Hormone therapy

Date completed:

What was the stage of the cancer?

What was the size of the tumor?

Were lymph nodes involved?

No Yes

How many?

List all medications being taken now for this condition:

Any evidence of recurrence since treatment completed?

No Yes

Please provide details:

Date cancer was declared "in remission":

Date and results of last mammogram:

Describe how well this condition is under control or if it restricts normal life in any way:

Leukemia Questionnaire

Please select type of leukemia:

Chronic Lymphocytic Leukemia

Hairy Cell Leukemia

Year of diagnosis:

Please note current stage of the leukemia:
Stage 0	Stage I	Stage II	Stage III	Stage IV

Are you on any medications?

No Yes

Please provide details:

Have any of the following tests been done? If so, please give date and results:

Date of test:
Hemoglobin:
White blood cell count:
Platelet count:

Describe how well this condition is under control or if it restricts normal life in any way:

Year of diagnosis:

Please note type of treatment (check all that apply):
Close observation only	Pentostatin
Splenectomy	Bone marrow transplant
Interferon	2-cdA
Other

Are you on any medications?

No Yes

Please provide details:

Please provide the results of your most recent CBC (complete blood count):

Date of test:
Hemoglobin:
White blood cell count:
Platelet count:

Has there been any evidence of recurrence?

No Yes

Please provide details:

Describe how well this condition is under control or if it restricts normal life in any way:

Melanoma Questionnaire

Year of diagnosis:

Please note where the melanoma was located:

Which type of melanoma were you diagnosed with?
Superficial Spreading Melanoma	Nodular Melanoma
Lentigo Maligna Melanoma	Acral Lentiginous Melanoma
Other:

For malignant melanoma only. Please provide all items:
Stage (if available)
Ulcerated?	No Yes
Clark's Level
Thickness in mm
Any positive Lymph Node?	No Yes
Details:

Has the cancer metastasized (spread) beyond the skin?

No Yes

Please provide details:

Has there been any evidence of recurrence?

No Yes

Please provide details:

List all medications being taken (include inhalers):

Describe how well this condition is under control or if it restricts normal life in any way:

Prostate Cancer Questionnaire

Date of biopsy:

Month Year

How was the cancer treated?
Observation only	TURP (Transurethral Prostatectomy)
Radical Prostatectomy	Radiation Therapy (Seed implant or external beam radiation)
Date radical prostatectomy completed:	Month Year
Hormone therapy	Other:

Date treatment completed:

List medications being taken now for any condition:

What stage was the cancer?

What was the Gleason score (scale of 1-10)?

When was the most recent PSA test?

What was the result of the most recent PSA test?

Less than 1 1 or higher

Please provide the most recent PSA level:

What was the PSA prior to treatment?

Has there been any evidence of recurrence?

No Yes

Describe how well this condition is under control or if it restricts normal life in any way:

Skin Cancer Questionnaire

Year of diagnosis:

What type of skin cancer was diagnosed?
Basal cell carcinoma	Squamous cell carcinoma

Please note where the skin cancer was located:

Has the cancer metastasized (spread) beyond the skin?

No Yes

Please provide details:

Has there been any evidence of recurrence?

No Yes

Please provide details:

Are you on any medications?

No Yes

Please provide details:

Describe how well this condition is under control or if it restricts normal life in any way:

Cancer Questionnaire

Tissue of origin and type of cancer diagnosis (e.g. colon, liver, etc.)

Year of diagnosis:

Grade, stage, and/or tumor size:

Did the cancer metastasize?

No Yes

To where did it spread?

How was the cancer treated?

Observation only

Date completed:

Surgery

Date completed:

Chemotherapy

Date completed:

Radiation therapy

Date completed:

Hormone therapy

Date completed:

Other:

Date completed:

Date cancer was declared "in remission":

Any evidence of recurrence since treatment completed?

No Yes

Please provide details:

List all medications being taken now for this condition:

Date and results of last doctor visit for this condition:

Describe how well this condition is under control or if it restricts normal life in any way:

Colitis / Ileitis Questionnaire

Year of diagnosis:

Please note the type of inflammatory bowel disease present:

Chronic Ulcerative Colitis

Chronic Proctitis (inflammation in rectum only)

Are you on any medications?

No Yes

Details:

Please check if you have had:

hospitalizations for this disorder (list dates)	List Dates:
surgery for this disorder (list dates)	List Dates:
colonoscopy (list dates of most recent)	List Dates:

Describe how well this condition is under control or if it restricts normal life in any way:

COPD Questionnaire

Year of diagnosis:

Have you ever had any of the following occurrences or symptoms?
Chronic Bronchitis	Emphysema
Restrictive Lung Disease	Asthma

List all medications being taken (include inhalers):

Have you ever had any abnormalities associated with ECG or x-ray?

No Yes

Please provide details:

Have pulmonary function tests (a breathing test) ever been done?

No Yes

Please provide details:

Have you ever been hospitalized for this condition?

No Yes

Please provide details:

Describe how well this condition is under control or if it restricts normal life in any way:

Crohn's Disease Questionnaire

Year of diagnosis:

Have you ever had any of the following occurrences or symptoms?
Hospitalizations for this disorder	Date(s):
Surgery for this disorder	Date(s):
Colonoscopy	Date(s):

List all medications being taken (prescription and non-prescription):

Describe how well this condition is under control or if it restricts normal life in any way:

Anxiety/ADD/Depression/Mental Illness Questionnaire

Indicate diagnosis:

Anxiety/ADD/ADHD

When was the condition diagnosed?

Are you now taking any medication for this condition?

No Yes

List the medication(s) and daily dosage:

Popular Medication Selector

Have you received, or are you receiving disability benefits for this condition?

No Yes

Have you had accidents at work or while driving?

No Yes

Details:

Depression

When was the condition diagnosed?

What caused the condition?

Are you now taking any medication for this condition?

No Yes

List the medication(s) and daily dosage:

Popular Medication Selector

Are you seeing, or have you seen a therapist for this condition?

No Yes

List date of last consultation:
NOTE: If applicant is currently taking medication for anxiety, ADD, depression or mental illness, most, if not all, life companies will want to see a doctor visit within last 12 months to prove that patient is compliant and receiving ongoing psychiatric care.

Have you received, or are you receiving disability benefits for this condition?

No Yes

Have you ever been hospitalized for this condition?

No Yes

Details:

Mental Illness

When was the condition diagnosed?

What is the specific condition (i.e bi-polar disorder, schizophrenia, anorexia, etc.)?

Are you now taking any medication for this condition?

No Yes

List the medication(s) and daily dosage:

Popular Medication Selector

Are you seeing, or have you seen a therapist for this condition?

No Yes

List date of last consultation:
NOTE: If applicant is currently taking medication for anxiety, ADD, depression or mental illness, most, if not all, life companies will want to see a doctor visit within last 12 months to prove that patient is compliant and receiving ongoing psychiatric care.

Have you received, or are you receiving disability benefits for this condition?

No Yes

Have you ever been hospitalized for this condition?

No Yes

Details:

Do you have a history of substance abuse (alcohol or drug)?

No Yes

Details:

Have you been hospitalized, required ECT, been seen in the emergency room, or been on disability for psychiatric symptoms or treatment?

No Yes

Details:

Have you lost time from work because of this condition?

No Yes

How many weeks of work did you miss?

Are you taking more than one medication for this condition?

No Yes

List medications and dosages:

Any history of suicide attempt or ideation?

No Yes

Details:

Any history of alcohol abuse or adverse driving?

No Yes

Details:

Describe how well this condition is under control or if it restricts normal life in any way:

Diabetes Questionnaire

What type of Diabetes?

Age at diagnosis:
*Use a numeric value for the age at diagnosis.*

What was your most recent hemoglobin A1c?

What was your most recent blood sugar reading?

Do you monitor your own blood sugar?

No Yes

How often do you visit your physician?

Date you last visited your physician:

The diabetes is controlled by:

Diet alone
Oral medication	Medication and dosage: Medication Selector:
Insulin	Amount of units/day:

Are you on any other medications?

No Yes

Details:

Please check if you have had any of the following:

Chest Pain or coronary artery disease	Overweight
Protein in the urine	Elevated lipids
Neuropathy	Black out spells
Retinopathy	Hypertension
Abnormal ECG

Describe how well this condition is under control or if it restricts normal life in any way:

Emphysema Questionnaire

Year of diagnosis:

Type of lung disease:
Chronic Bronchitis	Emphysema
Restrictive Lung Disease	Asthma

Have you ever been hospitalized for this condition?

No Yes

Please provide details:

Are you on any medications (include inhalers)?

No Yes

Please provide details:

Have pulmonary function tests (a breathing test) ever been done?

No Yes

Please provide most recent results and date:

Do you have any abnormalities on an ECG or x-ray?

No Yes

Please provide details:

Describe how well this condition is under control or if it restricts normal life in any way:

Epilepsy Questionnaire

Year of diagnosis:

Please provide date of most recent episode:

Please provide number of episodes per year:

Please note type of seizure:

Complex/Partial Seizure	Tonic-Clonic Seizure
Absense Seizure	Myoclonic Seizure

Are you on any medications?

No Yes

Name of medication(s) amount and frequency:

Have you been hospitalized for treatment of epilepsy?

No Yes

Please give details:

Describe how well this condition is under control or if it restricts normal life in any way:

Chronic Pain / Fibromyalgia Questionnaire

Year of diagnosis:

Is the pain localized or widespread?

Are you taking any medication?

No Yes

Which medication(s)? Include dosage:

Do you have any disabilities or physical impairments?

No Yes

Please provide details:

Do you have a history of mental illness?

No Yes

Please provide details:

Do you drink alcohol?

No Yes

How much and how often?

Describe how well this condition is under control or if it restricts normal life in any way:

Gout Questionnaire

Year of diagnosis:

What is the date of your last attack?

How frequent are attacks?

Are you taking any medication?

No Yes

Please provide details:

Are there joint deformities?

No Yes

Do you have any physical impairments?

Do you drink alcohol?

No Yes

What amount and frequency?

Describe how well this condition is under control or if it restricts normal life in any way:

Hepatitis/Liver Disease Questionnaire

Year of diagnosis:

What is the diagnosis?
Hepatitis A	Hepatitis B, resolved
Hepatitis B, carrier or chronic infection	Hepatitis C (non-A/non-B)
Jaundice	Fatty Liver
Cirrhosis	Other:

Have any of the following tests been done?
Liver Enzyme Tests	Date:
AST/SGOT	Result:
ALT/SGPT	Result:
GGPT	Result:

Liver ultrasound

Normal

Abnormal

CT scan/MRI

Normal

Abnormal

Liver Biopsy

Normal

Abnormal

Do you drink alcohol?

No Yes

What amount and frequency?

What type(s) of treatment have been/are being done?

Observation

Medication

Details:

Surgery

Date:

Have you been treated with interferon or anti-viral drugs?

No Yes

Please provide details:

Describe how well this condition is under control or if it restricts normal life in any way:

Hypothyroidism Questionnaire

Year of diagnosis:

Is this condition under control?

Has an ultrasound or radioactive scan of the thyroid been done?

No Yes

What were the results?

Are you taking any medications?

No Yes

Medication name, amount and frequency:

Medication Selector:

Are your thyroid levels normal?

No Yes

Describe how well this condition is under control or if it restricts normal life in any way:

Kidney Disease Questionnaire

Please select type:

Glomerulonephritis	Kidney Transplant
Proteinuria	Polycystic Kidney Disease

Year of diagnosis:

Please note type of Glomerulonephritis:

Was a kidney biopsy done?

No Yes

Please give date and diagnosis:

Are you on any medications?

No Yes

Please provide details:

Please provide the your most recent readings for:

Blood Pressure
BUN
Creatinine
Urinalysis

Describe how well this condition is under control or if it restricts normal life in any way:

Please list date(s) of transplant(s):

Please check cause of the end stage renal disease which led to the transplant:
Diabetes	Polycystic Kidney Disease
Glomerulonephritis	Ephrosclerosis
Systemic Lupus Erythematosus	Other

What was the source of the donor kidney?

Cadaver Identical Twin Living Related Donor

Are you on any medications?

No Yes

Please provide details:

Please provide the most recent results of the following kidney function tests:

BUN
Serum Creatinine
Urinalysis

Please note if any of the following have occurred (check all that apply):
Frequent Infection	Toxicity From Treatment
Rejection Episodes	Cancer
High Blood Pressure	Disease Recurrence
Cardiovascular Disease

Describe how well this condition is under control or if it restricts normal life in any way:

How long in years has this abnormality been present?

Has a specific cause for the proteinuria been found?

No Yes

Please provide details:

Please give the date and results of the most recent urinalysis:

Protein
Red Blood Cells (RBC's)
White Blood Cells (WBC's)
Protein/Creatinine Ratio

Please check if you have had any of the following:
Weight Loss	Biliary Cirrhosis
Heart Disease	Liver Enzyme Abnormality
Lung Disease	Kidney Disease
Raynaud's Disease	Trouble Swallowing

If any of the following urinary tests have been completed, please give the date and result:

Microalbumin
24-hour Protein
24-hour Creatinine Clearance
Other

Are you on any medications?

No Yes

Please provide details:

Describe how well this condition is under control or if it restricts normal life in any way:

Do any other family members have ADPKD?

No Yes

Please provide details:

Was ADPKD diagnosed by ultrasound?

No Yes

Please provide the date and results of your most recent urinalysis.

Protein
Red blood cells (RBC)
White blood cells (WBC)
Protein/Creatinine ratio

Please provide the date and results of the most recent kidney function tests.

BUN
Serum Creatinine

Are you currently on any medications?

No Yes

Please give date and diagnosis:

Describe how well this condition is under control or if it restricts normal life in any way:

Lupus Questionnaire

Year of diagnosis:

Which type of lupus?
Systemic Lupus Erythematosus	Discoid Lupus
Drug Induced Lupus

Are you taking any medication for this condition?

No Yes

Details:

Are you currently receiving any other treatment for this condition?

No Yes

Details:

Is the lupus active?

No Yes

How long has it been in remission?

Please check if you have any of the following:
Low blood counts	Lung involvement
Proteinuria	High blood pressure
Neurologic disorder	Heart involvement (pericarditis)
Renal insufficiency or failure

Describe how well this condition is under control or if it restricts normal life in any way:

Mitral Valve Prolapse Questionnaire

Year of diagnosis:

How long has this abnormality been present?

Have you ever had any of the following occurrences or symptoms?
Chest Pain	Palpitations
Trouble Breathing	Dizziness

Is the MVP associated with regurgitation?

No Yes

Is there a history of any other heart disease in addition to the mitral valve prolapse (problems with other valves, coronary artery disease, etc.)?

No Yes

Please provide details:

Has an echocardiogram (ultrasound of the heart) been done?

No Yes

Please provide details:

Is there a murmur?

No Yes

What is the grade?

List all medications being taken now for any condition:

Describe how well this condition is under control or if it restricts normal life in any way:

Multiple Sclerosis Questionnaire

Year of diagnosis:

Please indicate the number of episodes and date of last episode:

Are you on any medications?

No Yes

Details:

Please note current neurologic status and/or symptoms.
normal	minimal residual impairment
moderate residual impairment	severe residual impairment

Please specify:

Please provide all MRI brain scan reports:

Describe how well this condition is under control or if it restricts normal life in any way:

Parkinson's Disease Questionnaire

Year of diagnosis:

Please note the functional stage of you currently:
Stage I	unilateral involvement
Stage II	bilateral involvement but normal stance
Stage III	bilateral involvement with mild postural imbalance but able to lead an independent life
Stage IV	bilateral involvement with postural instability, requires substantial help
Stage V	severe disease; restricted to bed or wheelchair

Has there been any evidence of progression?

No Yes

Please provide details:

Are you on any medications for this condition?

No Yes

Please provide details:

Please note if any of the following have occurred (check all that apply):
Dementia	Recurrent Infections
Memory Problems	Falls
Aspiration	Recurrent Injuries
Depression

Describe how well this condition is under control or if it restricts normal life in any way:

Prostate Issues (no cancer)

Year of diagnosis:

Is there a history of abnormal PSA levels?

No Yes

What is your most recent PSA reading?

Normal Prostate Specific Antigen (PSA) ranges by age
Age Range (Years)	Asian Americans	African Americans	Caucasians
40 to 49	0 to 2.0 ng/mL	0 to 2.0 ng/mL	0 to 2.5 ng/mL
50 to 59	0 to 3.0 ng/mL	0 to 4.0 ng/mL	0 to 3.5 ng/mL
60 to 69	0 to 4.0 ng/mL	0 to 4.5 ng/mL	0 to 4.5 ng/mL
70 to 79	0 to 5.0 ng/mL	0 to 5.5 ng/mL	0 to 6.5 ng/mL

What is the date of your last colonoscopy or biopsy?

What were the results?

Is surgery pending?

No Yes

Is there a history of any other conditions related to the prostate?

No Yes

Please provide details:

Are you now taking any medication for this condition?

No Yes

List the medication(s) and daily dosage:

Describe how well this condition is under control or if it restricts normal life in any way:

Sarcoidosis Questionnaire

Year of diagnosis:

Was a biopsy done?

No Yes

Please indicate the stage of the sarcoidosis:
0	1	2	3	4

How was the sarcoid treated?

No treatment Prednisone

Are you on any medications?

No Yes

Name of medication(s) amount and frequency:

What organs were involved?

Lung	Heart
Liver or Spleen	Eyes
Kidney	Central Nervous System
Skin	Lymph Nodes

Have you had any recent pulmonary function tests done?

No Yes

Please provide the results:

Has there been any evidence of recurrence or progression?

No Yes

Please provide details:

Describe how well this condition is under control or if it restricts normal life in any way:

Sleep Apnea Questionnaire

Year of diagnosis:

Has a sleep study been recommended?

No Yes

Was it completed?

No Yes

Date completed:

Why has it not been completed?

Was the sleep apnea diagnosed as:

Obstructive

Central

Unknown

How is the sleep apnea being treated?

Observation alone

Weight loss

C PAP/BiPAP mask

Surgery

Other

Details:

Are you on any medications?

No Yes

Name of medication(s) amount and frequency:

What was your last AHI (apnea-hypopnea index) reading?

OR I don't know

What was your last O2 (Oxygen) Saturation Level reading?

OR I don't know

Please check if you have had any of the following:

Lung disease	Accidents such as motor vehicle accidents
Heart disease	Arrhythmia
Stroke	Depression
Hypertension	Sarcoidosis

Describe how well this condition is under control or if it restricts normal life in any way:

Stroke Questionnaire

Please indicate date(s) of episodes(s):

Do you have any current neurological residuals?

No Yes

Please provide details:

Have you ever had any of the following occurrences or symptoms?
High Blood Pressure	High Cholesterol
Coronary Artery Disease	Atrial Fibrillation
Diabetes	Peripheral Vascular Disease
Heart Murmur	Carotid Disease

Describe how well this condition is under control or if it restricts normal life in any way:

Do you have any health conditions or non-medical situations that have not already been disclosed?

Yes

What was the medical condition?

List any medications used in treatment of this condition along with the dosage:

What was the date of diagnosis?

List any additional medical condition if applicable:

List any medications used in treatment of this condition along with the dosage:

What was the date of diagnosis?

List any additional medical condition if applicable:

List any medications used in treatment of this condition along with the dosage:

What was the date of diagnosis?

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