Respiratory Disorders Questionnaire

DATE

ADVISOR NAME

PHONE ex. 555-555-1212

FAX ex. 555-555-1212

Client Information

PROPOSED INSURED

DATE OF BIRTH

Male Female

STATE OF SALE

OTHER COMPANY ACTIONS:

Rated

Postponed Declined

OTHER COMPANY DETAILS:

ANY WEIGHT CHANGE IN THE LAST YEAR?

No Yes

IF YES, HOW MUCH?

REASON FOR CHANGE?

DATE OF DIAGNOSIS:

HAS THE PROPOSED ENSURED EVER SMOKED CIGARETTES?

Yes No Quit

IF YES, HOW MUCH?

QUIT, WHEN?

HAS A PULMONARY FUNCTION TEST BEEN PERFORMED?

No Yes

IF YES, WHEN?

RESULTS:

HAS A CHEST X-RAY OR EKG BEEN PERFORMED?

No Yes

IF YES, WHEN?

RESULTS:

HOW MANY EPISODES HAS THE PROPOSED INSURED HAD IN THE PAST YEAR THAT REQUIRED THEM TO VISIT THE EMERGENCY ROOM OR SEE THEIR PHYSICIAN FOR TREATMENT?

HAS THE PROPOSED INSURED EVER BEEN HOSPITALIZED FOR THIS CONDITION?

No Yes

IF YES, PLEASE PROVIDE DETAILS (DATES, HOSPITALS, ETC.):

HOW IS CONDITION BEING TREATED (BREATHING MACHINE, OXYGEN, MEDICATIONS, ETC.)?

PLEASE LIST ANY MEDICATIONS BEING TAKEN (INCLUDING INHALERS AND MEDICATIONS USED “AS NECESSARY”):

DOES PROPOSED INSURED HAVE ANY RESTRICTIONS ON DAY-TO-DAY ACTIVITIES?

No Yes

IF YES, PLEASE PROVIDE DETAILS:

DOES PROPOSED INSURED HAVE ANY OTHER MAJOR HEALTH PROBLEMS?

Yes No

IF YES, PLEASE PROVIDE DETAILS:

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Respiratory Disorders Questionnaire

Client Information