Impaired Risk Diabetes Questionnaire
Agent Information
Agent Name (required)
Address
Phone (required)
Fax
E-Mail (required)
LMG Marketing Rep:
Client Information
Client's name
Date of birth		mm    dd   yy
Sex		M    F
Height		Feet 2 ' 3 ' 4 ' 5 ' 6 ' 7 ' 8 ' 9 '   Inches 0" 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"
Weight (lbs.)
Smoker		Yes    No
		(if yes, also complete tobacco questionnaire)
Insurance amount
Insurance type		Select one Term UL Survivor UL
Additional insured's name (only if applying for Survivor UL)
Other company(s) actions
Date applied		mm   yy
Company
Declined
Postponed
Rated table
1. What was client's age when diagnosed with diabetes?
2. What method is used to control it?
Diet only Diet and oral medication (list) Diet and insulin injections
3. How often is insulin administered?
On an insulin pump 1 or 2 times per day 3 or more times per day
4. How often are sugar levels monitored?
1 or 2 times per day 3 or more times per day
5. When was the last visit to a physician?
0-6 months 6-12 months 12-24 months more than 24 months
6. Does the client have any of the following?
EKG abnormalities Insulin reactions Diabetic coma Any eye trouble Heart trouble Protein in urine Skin ulcerations Amputations Neuropathy or loss of feelings
other
7. Has client had a glycohemoglobin (AIC) test in the past 6 months?
Yes    No
8. If yes to #7, what was the level?
select one below 7.5 7.6-10 10.1-13 above 13
9. Is client receiving treatment or under supervision now?
Yes    No
10. How long has the glycohemoglobin level remained constant?
0-6 months 6-12 months more than 12 months
11. Date and result of last blood pressure reading, with or without medication.
mm   yy
12. Is cholesterol level below 200?
Yes    No
13. How many times per week does client exercise?
select one None 1 time per week 2 times per week 3 times per week 4 times per week 5 times per week 6 times per week 7 times per week More than 7
Type of exercise
14. Has either parent, or any sibling, died before age 65, other than by accident?
Yes No  (If yes, list relationship(s) and cause)
Relationship father mother sister brother    cause
Relationship father mother sister brother    cause
Relationship father mother sister brother    cause
Additional Information