MEDICAL CONDITONS LIST

This page is intended soley as a guideline to assist you in determing whether you or anyone in your family may have a condition subject to underwriting. This is not a form that is intended to be completed and submitted. Rather, it is merely a guideline. Please feel free to relate any relevant information onto the quote request form (examples might include latest blood pressure or cholesterol readings, etc.). If you prefer, it may be easier to *print* this page and circle any relevant condition(s).

Please review the following medical conditions to help in identifying any that you or any person applying for coverage were diagnosed with, received treatment for, or consulted a physician for in the past several years. These conditions may be associated with the specific medical category under which they’re listed, but primarily, they are intended to serve as examples of the medical category and do not necessarily include all the conditions related to that category. Therefore, if you have a particular illness or condition which does not appear on the list or you are uncertain which category it’s associated with, please discuss the issue with your licensed representative.

Lungs & Respiratory System Hayfever/allergies, sinus infections, asthma, bronchitis, tuberculosis, pneumonia, pneumothorax, emphysema, sleep apnea, chronic obstructive pulmonary disease, other.

Ears/Eyes/Nose Disorders Ear infections, ear tubes, hearing loss, speech/hearing impairment, meniere’s tinnitus, labyrinthitis, tonsils/adenoids, deviated septum, cataracts, glaucoma, other.

Heart/Circulatory High blood pressure, heart attack, chest pain, varicose veins, heart murmur, mitral valve prolapse, phlebitis, elevated cholesterol, peripheral vascular disease, irregular heart beat, other.

Blood Pressure & Cholesterol Readings Please provide the most current date and reading for blood pressure and cholesterol (including HDL, LDL and total cholelsterol) for each adult.

Male: BP_______________ Chl _______________ Female: _______________ Chl _______________

Diabetes/Thyroid Diabetes, high blood sugar, hyperglycemia, hypothyroid, low blood sugar, hyperthyroid, goiter, hypoglycemia, other.

Blood/lymph/anemia Anemia (type), swollen lymph nodes, lymphadenaopathy, other.

Cancer Provide location, type of cancer and any treatment received. If you do not know the specific diagnosis, contact your physician for that information, other.

Tumor/Cyst/Growth Tumor, growth, cyst, polyp, other.

Breast Breast implants, fibrocystic breast disease, other.

Skin Disorders Acne, rosacea, psoriasis, skin cancer, eczema, other.

Nervous System Disorders Unconsciousness, paralysis, cerebral palsy, stroke/mini-stroke, vertigo, multiple sclerosis, Bell’s palsy, Parkinson’s disease, epilepsy/seizures/convulsions, headaches/migranes, TIA (transient ischemic attack)/brain attack, other.

Mental/Nervous Disorders Emotional disorder, anorexia, schizophrenia, dysthymia, anxiety, bulimia, panic attacks, insomnia, depression, attention deficit disorder (ADD), obsessive compulsive disorder, oppositional deviant behavior, other.

Digestive Disorders Ulcer gastritis, heartburn, intestinal disorder, colitis, gallbladder, Chron’s, ulcerative colitis, irritable bowel syndrome, hemorrhoids, hernia, pancreas disorder, spleen, liver, hepatitis, GERD, jaundice, cirrhosis, other.

Bone/Muscle/Connective Tissue Disorders Arthritis, low back pain, ACL tear/back/spine disorder, osteoarthritis, scoliosis, bursitis/tendonitis, gout, fractures, spinal fusion, manipulation therapy, herniated disc, sprain/strain, chronic fatigue syndrome, carpal tunnel syndrome, lupus, joint replacement, muscular/neuromuscular disorder, degenerative joint disease, bunions, feet disorders, other.

Fixation/Prosthetic Devices Plates, implants, pacemaker, screws, breast implants, valve replacement, pins, shunts, joint replacment, other.

Urinary System Disorders Kidney stones, prostatitis, kidney disorder, cystitis, glomerulonephritis, bladder infections, nephritis, other.

Reproductive System Disorders Penis, ovaries, infertility, endometriosis, rectocele, PMS, testes, cervix, irregular menses, ovarian cyst, cystocele, polycystic ovarian disease, vagina, uterus, uterine fibroids, sexually transmitted diseases (STD’s), prolapsed uterus, benign prostatic hypertrophy, other.

Complications of Pregnancy Ectopic pregnancy, gestational diabetes, miscarriage, pre-term labor, pre-eclampsia, c-section, other.

Pap Smear DATE of LAST:________ RESULTS:________ Has a repeat pap been recommended?______ Cervical dysplasia, inflammation, cervicitis, cervical cancer, atypical squamous cells (ASCUS), other.

Immune Deficiency Swollen lymph nodes, chronic fatigue, skin rashes, depression, appetite loss, fever, unexplained infections, pneumonia, weight loss, oral thrush, dementia, psychoneurotic disorders, other.

Congenital Disorders/Birth Defects/Development Disorders Down syndrome, cleft lip/palate, speech therapy, mental retardation, club foot, occupational therapy, autism, congenital heart defects, physical therapy, other.

Diagnostic Testing EKG (electrocardiogram), stress test, CT scan, colonoscopy, EEG, blood test, chest x-ray, angiogram, ultrasound, EGD (endoscopy), bone density, echocardiogram, MRI, mammogram, holter monitor, urinalysis, other.

Hazardous Activities Racing (auto, motorcycle or boat), skydiving, hang gliding, ultralight flying, scuba.

Driving Record DUI (past 5 years), reckless driving, moving violations (last 2 years), speeding.

Rx Drugs Any current prescriptions? Last 3 months? Last 2 years? (Condition/diagnosis and dosage/frequency).