Applicant Name:

Are you dependent on a wheelchair or any motorized mobility device?	Y N
If yes, explain:
Do any of the following apply to you?
Currently hospitalized, confined to a bed, in a nursing facility or assisted living facility, receiving home health care or physical therapy	Y N
If yes, explain:
At any time, have you been medically diagnosed, treated, or had surgery for any of the following?
Congestive heart failure, unoperated aneurysm, defibrillator	Y N
If yes, explain:
Leukemia, lymphoma, multiple myeloma, cirrhosis	Y N
If yes, explain:
Parkinson's Disease, Lou Gehrig's Disease, Alzheimer's Disease, dementia, multiple sclerosis, muscular dystrophy, cerebral palsy	Y N
If yes, explain:
Chronic kidney disease, kidney failure, kidney disease requiring dialysis, renal insufficiency, Addison's Disease	Y N
If yes, explain:
Any condition requiring a bone marrow transplant or stem cell transplant, any condition requiring an organ transplant	Y N
If yes, explain:
Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), tested positive for the Human Immunodeficiency Virus (HIV)	Y N
If yes, explain:
Do you have diabetes?
That requires use of insulin	Y N
If yes, explain:
With complications including retinopathy, neuropathy, peripheral vascular or arterial disease or heart artery blockage	Y N
If yes, explain:
With history of heart attack or stroke (at any time)	Y N
If yes, explain:
Treated with medication that has been changed or adjusted in the past 12 months because of uncontrolled blood sugar	Y N
If yes, explain:
Within the past 36 months, have you been medically diagnosed, treated, or had surgery for any of the following?
Alcoholism, drug abuse	Y N
If yes, explain:
Cardiomyopathy, atrial fibrillation, anemia requiring repeated blood transfusions, any other blood disorder	Y N
If yes, explain:
Internal cancer, melanoma, Hodgkin's Disease	Y N
If yes, explain:
Hepatitis, disorder of the pancreas	Y N
If yes, explain:
Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?
Enlarged heart, transient ischemic attack (TIA), stroke, peripheral vascular or arterial disease, neuropathy, amputation caused by disease	Y N
If yes, explain:
Myasthenia gravis, systemic lupus or connective tissue disorder	Y N
If yes, explain:
Osteoporosis with fractures, Paget's Disease, arthritis that restricts mobility or the activities of daily living	Y N
If yes, explain:
Any lung or respiratory disorder requiring the use of a nebulizer or oxygen, or 3 or more medications for lung or respiratory disorder	Y N
If yes, explain:
Any lung or respiratory disorder and currently use tobacco products	Y N
If yes, explain:
Within the past 12 months, have you been advised by a medical professional to have treatment, further evaluation, diagnostic testing, any surgery that has not been performed or any pending test results?	Y N
If yes, explain:
Within the past 12 months, have you been medically diagnosed or, treated, or had surgery for a heart attack, artery blockage, or heart valve disorder?	Y N
If yes, explain:
Within the past 12 months, have you been medically diagnosed with wet macular degeneration and have taken or are currently receiving injections?	Y N
If yes, explain:
Have you used any form of tobacco in the past 12 months?	Y N
If yes, explain:
Within the past 12 months, do any of the following apply to you?
had a pacemaker implanted	Y N
If yes, explain:
had a PSA blood test greater than 4.5, under age 70, with no history of prostate cancer	Y N
If yes, explain:
had a PSA blood test greater than 6.5, age 70 or older, with no history of prostate cancer	Y N
If yes, explain:
had a seizure	Y N
If yes, explain:
Was your last blood pressure reading higher than 175 Systolic or higher than 100 Diastolic?	Y N
If yes, explain:
Height (feet and inches) Weight (Pounds)
Health History
Within the past 24 months if you have been medically diagnosed, treated, or had surgery for any brain, mental or nervous disorder, provide reason and diagnosis:
Within the past five years if you have been hospitalized, treated at an outpatient facility, or emergency room, provide reason and diagnosis:
Prescribed Medication Reason for medication (diagnosis)
Physician Information
Your Primary physician: Phone: Physician's Office Name: Physician's Office city: Physician's Office state Specialist seen in the past 24 months: Specialty: Reason for seeing (diagnosis): Specialist seen in the past 24 months: Specialty: Reason for seeing (diagnosis): Specialist seen in the past 24 months: Specialty: Reason for seeing (diagnosis):
Have you seen any additional physicians other than those listed above in the past 24 months?	Y N