3. Please indicate if you have had any of the following: EKG Abnormality. insulin reaction eye trouble. protein in urine. skin ulceration. amputation …
DIABETES QUESTIONNAIRE Name: ____________________________________ Date of Birth: _____________________ Height _____ Weight _____ Cigarette Smoker: Yes No Quantity per day: _____ 1 Age at onset of diabetes? __________________________________________________
2 What is the method of control? ______________________________________________ 3 Please indicate if you have had any of the following: EKG Abnormality insulin reaction diabetic coma eye trouble protein in urine skin ulceration amputation neuropathy / loss of feeling other ____________________ 4 How often do you monitor blood sugar levels and what was the most recent reading? ______________________________________________________________________ Indicate most recent blood pressure reading to the best of your knowledge: ____/____ Last time you visited a physician? ___________________ 
_______________________ Is your cholesterol below 200? _____________________________________________
5 6 7
Name and address of all physicians/hospitals with medical records:_____________________ ___________________________________________________________________________
___________________________________________________________________________ Notes/comments:_____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Signature of Proposed Insured: ______________________________ Date: _____________ Witnessed by: ____________________________________________
PO Box 4763, Syracuse NY, 13221-4763, 800-959-3894
11/05
Source:usfli.com
