Life Insurance Medical Exam

Personal Information

Medical History

Have you been diagnosed with any chronic illnesses? Yes No If yes, please specify: Do you take any medication regularly? Yes No If yes, list the medications: Do you have any allergies? Yes No If yes, specify allergies:

Lifestyle

Do you smoke? Yes No Former Smoker Do you consume alcohol? Yes No Do you exercise regularly? Yes No If yes, how many times per week?

Family Medical History

Has any immediate family member been diagnosed with serious illnesses (e.g., cancer, heart disease, diabetes)? Yes No If yes, specify relationship and illness:

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