Impaired Risk Questionnaire For Diabetes
Diabetes involves impaired risk underwriting, where a person whose physical condition is less than standard or
who has a hazardous occupation or hobby, to help obtain the best tentative offers by several top rated life insurance
Please submit a completed form below to shop for the best possible premium:
* required information
**Please use TAB key to proceed to the next question field, not the ENTER key.**
Date Of Birth:
Type of Product:
Second to Die
Has your client ever used tobacco or nicotine products?
If yes, what type of product did you use? (Select all that apply)
2. Date diagnosed?
3. Type of medication and dosage:
4. Has your client ever been hospitalized for diabetes?
5. When did your client last see your doctor?
How often does your client visit?
6. Does your client have glycohemoglobin AIC tests done?
Does your client test his/her own sugar?
Does your client know the most recent result?
Date of last blood glucose level:
s your client
and your client's doctor pleased with your client's control?
7. Has your client had any kidney problems?
Any protein in the urine?
8. Has your client had any problem with his/her eyes?
9. Any high blood pressure?
10. Any "heart trouble"?
(If Yes, Please complete the Heart Questionnaire also.)
11. Any neurological symptoms, loss of feeling in your client's feet?
12. Additional Comments?