Insurance Step 1 of 24 4% Name First Last Gender*MaleFemaleDate 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?YesNoDo you have a spouse or significant other?YesNoHeight (ft./in.)Weight (lbs)Have you used any tobacco products in the last 5 years?*YesNoHave 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?YesNoHave you had your license suspended or revoked, or had more than one ticket or accident in the past 5 years?YesNo Have you ever been treated for alcohol abuse?YesNoWhen was your most recent treatment? MM DD YYYY Have you ever been treated for drug abuse?YesNoWhen was your most recent treatment? MM DD YYYY When were you first diagnosed or treated for anxiety? Date Format: MM slash DD slash YYYY What was your diagnosis? Select a severityMildModerateSevereWhen was your most recent occurrence or episode? Date Format: MM slash DD slash YYYY Are you currently taking any medications?YesNoHow many medications?12345678910Have you been hospitalized or missed any work due to anxiety?YesNoPlease enter any other relevant details (Optional) When were you diagnosed with asthma? Date Format: MM slash DD slash YYYY What was your diagnosis?MildModerateSevereHave you ever been medically treated for asthma?YesNoAre you currently being medically treated for asthma?YesNoWhich of the following treatment type(s) have you used? Inhaled bronchodilators Inhaled corticosteroids Oral medication (no steroids) Oral medication (with steroids) Rescue inhaler On average, how many asthma attacks do you have per year?012345678910Select the number of yearly episodes Have you ever been hospitalized due to asthma?yesNoHow many times have you been hospitalized in the past year due to asthma?012345678910How many times have you been hospitalized in your entire life due to asthma?012345678910When was the last hospitalization? Date Format: MM slash DD slash YYYY What is the most serious type of cancer you have been diagnosed with?Select a cancerBasalBrain and other nervous systemBreastColonEsophagusGallbladderHodgkin lymphomaKidney and renal pelvisLeukemiaLiverLung and bronchusMelanomaMouthMyelomaNon-Hodgkin lymphomaOvaryPancreasPharynxProstateRectumSquamousStomachThyroidToungeUrinary bladderUterine cervixUterine corpusOtherWhen were you first diagnosed or treated? Date Format: MM slash DD slash YYYY What was the stage of the cancer?1234OtherWhen were you last treated? Date Format: MM slash DD slash YYYY Please enter any other relevant details When were you diagnosed with depression? Date Format: MM slash DD slash YYYY What was your diagnosis?MildModerateSevereAre you currently undergoing treatment for depression?YesNoHow many different types of medications are you currently taking?012345678910Are you currently in psychotherapy treatment?YesNoHave you ever taken medication or been in psychotherapy for depression?YesNoWhen did your treatment (either medication or therapy) end? Date Format: MM slash DD slash YYYY Have you ever been hospitalized due to depression?YesNo When were you diagnosed with diabetes? Date Format: MM slash DD slash YYYY Is this type 1 or type 2 diabetes?Type 1Type 2Was the diagnosis for gestational diabetes?YesNoWhat was your last A1C reading?Don't know5.05.15.25.35.45.55.65.75.85.96.06.16.26.36.46.56.66.76.86.97.07.17.27.37.47.57.67.77.87.98.08.18.28.38.48.58.68.78.88.99.09.19.29.39.49.59.69.79.89.910.010.110.210.310.410.510.610.710.810.911.011.111.211.311.411.511.611.711.811.912.0What's your average A1C reading for the last 12 months?Don't know5.05.15.25.35.45.55.65.75.85.96.06.16.26.36.46.56.66.76.86.97.07.17.27.37.47.57.67.77.87.98.08.18.28.38.48.58.68.78.88.99.09.19.29.39.49.59.69.79.89.910.010.110.210.310.410.510.610.710.810.911.011.111.211.311.411.511.611.711.811.912.0Have you had any complications from diabetes?YesNoAre you currently undergoing treatment for diabetes?YesNoWhen did your treatment end? Date Format: MM slash DD slash YYYY What's your daily dosage of insulin units?I don't use insulin2021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200 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?Don't knowless than 120120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250What is your diastolic pressure?Don't knowLess than 808081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180When 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?YesNoWhen did you start taking medication to control your blood pressure? Date Format: MM slash DD slash YYYY Cholesterol levelDon't know100201202203204205206207208209210211212213214215216217218219120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300HDL ratioDon't know2.52.62.72.82.93.03.13.23.33.43.53.63.73.83.94.04.14.24.34.44.54.64.74.84.95.05.15.25.35.45.55.65.75.85.96.06.16.26.36.46.56.66.76.86.97.07.17.27.37.47.57.67.77.87.98.08.18.28.38.48.58.68.78.88.99.09.19.29.39.49.59.69.79.89.910.010.110.210.310.410.510.610.710.810.911.011.111.211.311.411.511.611.711.811.912.0When were you last treated for high cholesterol? Date Format: MM slash DD slash YYYY Are you on any medication to control your cholesterol?YesNoWhen did you start taking medication to control your cholesterol? Date Format: MM slash DD slash YYYY When were you diagnosed with sleep apnea? Date Format: MM slash DD slash YYYY What was your diagnosis?MildModerateSevereHave you received treatment?YesNoWhen was the treatment? Date Format: MM slash DD slash YYYY Do you use a CPAP machine?YesNoHave you done an overnight sleep study?YesNoOxygen saturation (percentage)Apnea-hypopnea index (AHI)Events per hour of sleepApnea indexEvents per hour of sleepRespiratory disturbance index (RDI)Events per hour of sleep 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 futureNot sure yet Estimated Monthly Rate: $14.70Estimated Monthly Rate: $21.44Estimated Monthly Rate: $18.55Estimated Monthly Rate: $25.38 Estimated Monthly Rate: $14.61Estimated Monthly Rate: $21.00Estimated Monthly Rate: $16.19Estimated Monthly Rate: $24.50 Estimated Monthly Rate: $14.96Estimated Monthly Rate: $20.56Estimated Monthly Rate: $15.05Estimated Monthly Rate: $23.63 Estimated Monthly Rate: $15.31Estimated Monthly Rate: $22.75Estimated Monthly Rate: $17.33Estimated Monthly Rate: $25.38 Estimated Monthly Rate: $17.59Estimated Monthly Rate: $29.31Estimated Monthly Rate: $19.25Estimated Monthly Rate: $31.94 Estimated Monthly Rate: $19.43Estimated Monthly Rate: $37.19Estimated Monthly Rate: $22.40Estimated Monthly Rate: $43.31 Estimated Monthly Rate: $23.45Estimated Monthly Rate: $52.06Estimated Monthly Rate: $27.91Estimated Monthly Rate: $65.19 Estimated Monthly Rate: $28.53Estimated Monthly Rate: $74.38Estimated Monthly Rate: $36.49Estimated Monthly Rate: $93.19 Estimated Monthly Rate: $43.23Estimated Monthly Rate: 108.50Estimated Monthly Rate: $63.44Estimated Monthly Rate: $143.06 Estimated Monthly Rate: $71.31Estimated Monthly Rate: $171.94Estimated Monthly Rate: $101.94Estimated Monthly Rate: $198.19