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Applicant Information |
* Applicant Name : |
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* DOB: |
00/00/0000 |
* Gender: |
Male
Female
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* Height |
Ft/In |
* Weight |
lbs |
| * Occupation |
|
| * Death Benefit |
|
* Type of Product |
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Tobacco Use: |
Yes
No
|
Replacement? |
Yes
No
|
Current Annum Premium |
$
|
Last Life Ins. Application |
Year
Company
Action |
Occupation: |
|
Marital Status: |
Single
Married
Widow
Divorced |
Family History: (age if still living) |
Father
Mother
Sibling 1
Sibling 2
Sibling 3 |
If any deceased, give relation(s), age(s), and cause(s): |
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Driving Record:
|
Number of violations in past 3 years?
# of DUI / Reckless Driving in past 5 years?
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Do you exercise 3 or more times per week? If yes, please give details: |
Yes
No
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Date of last medical checkup: |
00/00/0000 |
Date of last EKG: |
00/00/0000
Results:
|
Last blood pressure reading: (results)
|
00/00 |
Are you treated for blood pressure? |
Yes
No
|
Last Cholesterol Reading, HDL reading (results): |
|
Are you treated for cholesterol? |
Yes
No
|
1. What disorder made the kidney transplant necessary? |
Kidney failure due to diabetes
Kidney failure due to glomerulonephritis
Kidney failure due to polycyctic kidney disease
Other, please specify:
|
2. Date of transplant? |
00/00/0000 |
3. Source of transplant kidney? |
Identical Twin
Related donor with identical HLA Match
Related donor without identical HLA Match
Non-Related live donor
Non-Related cadaver kidney |
4. Are there any symptoms/complications?
|
Yes
No
If yes, please explain:
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5. Give results of most recent kidney function tests: |
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6. Please note if any of the following have occurred (check all that apply): |
Frequent infection
Rejection episodes
High blood pressure
Cardiovascular disease
Toxicity from treatment
Cancer
Disease recurrence
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7. What treatment is currently being prescribed? |
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8. When was the last time a physician was consulted to follow up on the transplant? |
00/00/0000 |
9. List any other illnesses or impairments (complete any other quick quote forms that may apply) along with all meds and vitamins taken, include dosage and frequency: |
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| Please fill out all information completely and accurately. |
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