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Do you take any prescription medications currently or in the past 5 years?
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No
If yes, please explain:
Have you ever had a health condition such as cancer, heart disease, stroke, diabetes, sleep apnea, gastroesophageal issues, or any other major surgeries?
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No
If yes, please explain:
Ever used tobacco and/or nicotine products in any form?
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No
If yes, please share type of product, amount used, date of last use:
Have you in the past 5 years or do you currently use medical or recreational marijuana?
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No
If yes, please share type of product (edibles, liquid, inhaled, etc), number of uses per month, date of last use:
Any history of DUI or more than 1 moving violation in the last 5 years?
Yes
No
If yes, please explain
Do you participate in any dangerous or hazardous sports or activities (scuba, private aviation/piloting, motor vehicle racing, rock climbing, etc.)?
Yes
No
If yes, please explain:
Any cancer, diabetes, or heart disease diagnosis or death in either parent on or before age 65?
Yes
No
If so, please provide details:
Family History
Mother Age if Living
Age at Death
Father Age if Living
Age at Death
Sibling Age if Living
Age at Death
Sibling Age if Living
Age at Death
Sibling Age if Living
Age at Death
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Universal Life
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