Ask the Doctor – Diabetes

Obtain a tentative offer for a case involving Diabetes by completing the form below:

* required information

**Please use TAB key to proceed to the next question field, not the ENTER key.**

1. *Agent Name :
*Address :
*City :
*State :
*Zip :
Agent E-Mail:
Agent Phone :
2. Applicant’s Name:
Date Of Birth:
Sex:	Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product:	Term Universal Whole Life
	Second to Die Variable
Have you ever used tobacco or nicotine products?	Yes No If yes, what type of product did you use? (Select all that apply) Cigarettes Cigar Pipe Other
3. Date diagnosed?
4. Type of medication and dosage:
5. Have you ever been hospitalized for diabetes?	Yes No
	When? Duration?
6. When did you last see your doctor?
How often do you visit?
7. Do you have glycohemoglobin AIC tests done?	Yes No
	Result
Do you test your own sugar?	Yes No
Do you know the most recent result?	Yes No
When?
Date of last blood glucose level:
Result:
Are you and your doctor pleased with your control?	Yes No
8. Have you had any kidney problems?	Yes No
Any protein in the urine?	Yes No
9. Have you had any problem with your eyes?	Yes No
Any treatment?	When?
10. Any high blood pressure?	Yes No
	When?
11. Any “heart trouble”?	Yes No (If Yes, Please complete the Heart Questionnaire also.)
	When?
12. Any neurological symptoms, loss of feeling in your feet?
13. Additional Comments?