Blood Pressure Questionnaire

Obtain a tentative life insurance offer for an impaired underwriting risk that involves Blood Pressure by completing the form below: * required information **Please use TAB key to proceed to the next question field, not the ENTER key.**


 
Blood Pressure 


Applicant's Name*:


Applicant's Address*:
Applicant's Phone Number*:
Applicant's E-Mail Address*:
Date Of Birth:
Sex: Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Have you ever used tobacco or nicotine products? Yes No
If yes, what type of product did you use? (Select all that apply)
Cigarettes Cigar Pipe Other
2. When diagnosed?
3. Type of treatment? Diet: Weight Loss:
Salt Reduction:
Medication:
If applicable, list medications:
Do you take medications regularly? Yes No
4. Is your blood pressure controlled currently? Yes No
Last reading?
5. Any complications?
6. Has an electrogram been done? Yes No
7. Additional Comments?