Guidance For Client With Impaired Health Risk – Fact Finder

Agent First Name *

Agent Last Name *

Agent Email *

Agent Phone *

Client First Name *

Client Last Name *

Client Gender *

Client DOB *

State *

Tobacco User? *

Height *

Weight *

List all prescription medications - Include dosages and frequency *

List any significant health conditions - Include how treated and when diagnosed *

Previous Declinations (If Applicable)

Life carrier who declined policy
Date of the decline
Reason for the decline

Common impaired risk health issues (info we need if it applies)

Diabetes

Date Diagnosed
How is it treated? (diet, oral medication, insulin)
What was most recent A1C reading?
Any complications? (neuropathy, vision, kidney, heart issues)

Cancer

Date of diagnosis
Type of cancer
Stage
Class
Type of treatment (surgery, radiation, chemotherapy)
Date of last treatment
Is a pathology report available?

Pathology report if available

Heart Disease

Date of diagnosis
Was there a heart attack?
What type of treatment (angioplasty, bypass, medical management)?
How many vessels were involved?
What was the date of the last stress test and doctor visit?
Are the stress test results available?
Are risk factors being modified (cholesterol, blood pressure, smoking, build, regular exercise)?
Any current symptoms? (chest pain, shortness of breath, fatigue)

Stress Test Results if available

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