Financial Group - WebWriteIt

Name
First Last
Gender*
- Male
- Female
Date of Birth
MM
DD
YYYY
Age*
Please enter a number from 20 to 104.
Zip code
ZIP / Postal Code
Are you currently a U.S. citizen or permanent resident?
- Yes
- No
Do you have a spouse or significant other?
- Yes
- No
Height (ft./in.)
Weight (lbs)
Have you used any tobacco products in the last 5 years?*
- Yes
- No
Have you ever been treated for and/or taken medication for any of the following?
- Alcohol abuse
- Anxiety
- Asthma
- Cancer
- Depression
- Diabetes
- Drug abuse
- Heart Attack
- High blood pressure
- High cholesterol
- Sleep apnea
- Stroke
- Other serious condition
Do you have any parents or siblings who contracted cardiovascular disease (heart attacks or strokes), cancer, diabetes, or kidney disease before age 70?
- Yes
- No
Have you had your license suspended or revoked, or had more than one ticket or accident in the past 5 years?
- Yes
- No

When were you first diagnosed or treated for anxiety?
Date Format: MM slash DD slash YYYY
What was your diagnosis? Select a severity
- Mild
- Moderate
- Severe
When was your most recent occurrence or episode?
Date Format: MM slash DD slash YYYY
Are you currently taking any medications?
- Yes
- No
How many medications?
Have you been hospitalized or missed any work due to anxiety?
- Yes
- No
Please enter any other relevant details (Optional)

When were you first diagnosed or treated for a heart attack?
Date Format: MM slash DD slash YYYY
When was your most recent occurrence or episode?
Date Format: MM slash DD slash YYYY
Please enter any other relevant details (Optional)

What is your diastolic pressure?
What is your diastolic pressure?
When were you last treated for high blood pressure?
Date Format: MM slash DD slash YYYY
Are you on any medication to control your blood pressure?
- Yes
- No
When did you start taking medication to control your blood pressure?
Date Format: MM slash DD slash YYYY

Cholesterol level
HDL ratio
When were you last treated for high cholesterol?
Date Format: MM slash DD slash YYYY
Are you on any medication to control your cholesterol?
- Yes
- No
When did you start taking medication to control your cholesterol?
Date Format: MM slash DD slash YYYY

When were you first diagnosed or treated for a stroke?
Date Format: MM slash DD slash YYYY
When was your most recent occurrence or episode?
Date Format: MM slash DD slash YYYY
Please enter any other relevant details (Optional)

Please describe any other serious medical conditions you have, including the names of diagnoses or conditions.
When were you first diagnosed or treated?
Date Format: MM slash DD slash YYYY

When do you need to be covered?
- I need to be covered ASAP (average 4-6 weeks)
- I need to be covered sometime in the future
- Not sure yet