Diabetes Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Email
Date of Birth
When was diabetes diagnosed by a member of the medical profession? What type of diabetes have you been diagnosed Type I Type II with by a member of the medical profession? Please list all physicians that have treated you for your diabetes: (Provide names and addresses)
Date you last consulted above physician? How is your diabetes controlled?
Gestational
How often do you see? Diet
Oral Medications
Insulin
List all medications currently taken including diabetes medications: (Provide dosage and frequency.)
How often do you test your blood sugar? What are the results and the dates of the last three (3) fasting blood-sugar readings?
Questions
What are the dates and results of your last three (3) HgA1c (glycohemoglobin) readings? (At least one A1C score and date are required.) Have you ever been diagnosed by a member of the medical profession with: (If yes, provide details regarding diagnosis, dates, physicians and treatments.) a. Diabetic coma or insulin shock?
Yes
No
b. Heart trouble, TIA or stroke?
Yes
No
c. High blood pressure?
Yes
No
d. Kidney trouble or protein in urine?
Yes
No
e. Neuropathy or numbness/tingling?
Yes
No
f. Retinopathy or eye problems?
Yes
No
Details:
GBU FINANCIAL LIFE
FL20-DB.2
WWW.GBU.ORG | NEWBUSINESS@GBU.ORG PO BOX 645949, PITTSBURGH, PA 15264-5257 412-884-5100 | 800-765-4428
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Diabetes Questionnaire (continued)
Questions (Continued)
Have you ever been hospitalized due to your diabetes? (If yes, provide dates, names and addresses for all treatment locations.)
What is your current height and weight?
Height:
Yes
No
Weight:
Please provide any additional information you feel is important concerning your diabetes:
I declare that all statements and answers to the foregoing questions are, to the best of my knowledge and belief, complete and true. I agree (a) that they shall form a part of my application; (b) that they shall be subject to the terms of the agreement found in the application; and, (c) that they shall become part of any policy based on my application.
Acknowledgement
Fraud Warning. Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Signature of Proposed Insured or Guardian
FL20-DB.2
Date
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