Mental Nervous Disorder Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last)
Questions
Have you ever been diagnosed by a member of the medical profession with any of the following? (Check all that apply.)
Date of Birth Date of First Indication
What Was the Cause
Fatigue Anxiety Depression Significant Stress Bi-Polar Disorder Weight Loss Insomnia Nervousness Suicidal Thoughts PTSD (Post Traumatic Stress Disorder) Name/address of current physician(s) or other medical practitioner(s) treating or monitoring the above?
Date you last consulted above physician(s) or other medical practitioner(s)?
How often do you see this physician(s) or other medical practitioner(s)? Have you ever consulted any other physician(s) or other medical practitioner(s) regarding the above? Have you ever received any treatment or medications from a member of the medical profession for any of the above conditions? (If yes, please explain.)
A member of the medical profession has diagnosed my symptoms as:
Improved
Similar
Yes
No
Yes
No
More Severe
Are you still under treatment or taking medication? Please provide details as to the type of treatment and what prescription medication(s) is/are taken, and what are the dosages and frequency for each.
Have you ever been hospitalized or recommended to be hospitalized or had any tests done in connection with the above?
Yes
No
Yes
No
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FL20-MND.2
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Mental Nervous Disorder Questionnaire (continued) Questions (continued)
Have you ever had time off from work due to the above condition? (If yes, dates and length of time off.)
Yes
No
Yes
No
Have you ever received treatment or counseling from a member of the medical profession for excessive use of alcohol?
Yes
No
Have you ever used marijuana or other drugs without a prescription?
Yes
No
Do you drink alcoholic beverages? (If yes, please explain what type, how often, how much per occasion and past usage.)
Provide any details or explanation you choose regarding the above conditions. 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-MND.2
Date
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