Qualification Questionnaire

2Occupation Information

3Medical History

Name *

First

Last

Email *

Date of Birth *

Gender *

Height *

Weight *

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Tobacco Consuption

Alcohol Consumption

Have You Ever Been Advised to Reduce Your Drugs or Alcohol Consumption by a Health Professional?

Have You Ever Received Premium Surcharge or Been Declined for Any Life or Health Insurance Applications?

Have You Ever Received Compensation for an Accident/Illness or Received Disability Benefits

Do You Have Any Medical Complications?

Do You Currently Take Any Prescription Medications?

Have You Ever Been Diagnosed With Any Form of Cancer?

In the Last 5 Year, Have You Been Advised to Consult a Physiotherapist or Chiropractor for Any Chronic Muscularskeletal Condition?

Have You Ever Had a Cardiac Event that Required Hospitalization?

Have You had Any Abnormal Test Results Relating to Your Health in the Last 5 Years?

Have You Been Hospitalized in the Last 5 Years?

Has One or More Members of Your Immediate Family Been Diagnosed with Heart Attack, Stroke, or Cancer Before the Age of 60?

Father, mother, brothers or sisters

Has One or More Members of Your Immediate Family Been Diagnosed with Any Degenerative or Chronic Health Condition prior to age 60?

Father, mother, brothers or sisters

Do Any Pre-Existing Medical Conditions Require Coverage?

Comments / Other Relevant Information

Phone

Disclosure

This medical questionnaire is not an application for health or life insurance. It used by your Red Helm Insurance advisor to help you determine which plan is most suitable for you. Your health information will not be shared with any 3rd party and is strictly used to provide advice related to the application of life or health insurance.

Disability Insurance - Qualification Questionnaire

Qualification Questionnaire

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