Blood In The Urine (Hematuria) Questionnaire (Page 2 of 2) in pdf

B L O O D I N T H E U R I N E ( H E M A T U R I A ) Q U E S T I O N N A I R E

Agent:

Phone:

Fax:

Proposed Insured Name: ___________________________________ r M

r F

Date of Birth: ______________________

r UL

r WL r Term

r Survivorship

Face Amount: _____________________ Max. Premium: $__________/year

Do you currently smoke cigarettes? r Y r N

If no, did you ever smoke: r Never r Quit (Date): ________________________

Do you currently use any other tobacco products (e.g. cigars, pipe, snuff, nicotine patch, Nicorette gum...): r Y r N

If Yes, please provide details: ____________________________________________________________________________________

When did you last use any form of tobacco: _____ (Month) _____ (Year) Type used last: ____________________________________

Note: In order to assess the possibility of obtaining life insurance with the presence of kidney disease, it is helpful to obtain results to

many of the test related questions below. A quick call by the proposed insured to their health care provider may indicate many of the

test results requested. Alternatively, perhaps the health care provider may be willing to fax the latest lab findings, avoiding the delays

of waiting for a formal APS. If this initial investigation indicates only minor abnormalities, and offers of insurance are likely, a full

APS, as well as current lab studies, will be requested by the insurance company during the formal application process.

(1) Please provide date of first diagnosis with kidney disease: ___________________________________________________________

(2) Please indicate the specific name of the kidney disorder diagnosed by your physician: ____________________________________

(3) Please provide approximate dates and readings of known blood pressure measurements:

Approximate date(s):

Systolic/Diastolic reading(s):

Approximate date(s):

Systolic/Diastolic reading(s):

(4) Please advise of the following laboratory findings, if previously (and recently) done by your physician?

Laboratory findings of:

Date of most recent test:

Level of findings:

Normal reference range:

Protein in the urine (proteinuria):

Blood in the urine (hematuria):

Blood urea nitrogen (BUN) level:

Creatinine level:

(5) Does the proposed insured take any medications? If yes, please list:

Name of Medication (Prescription or Otherwise)

Dates used

Quantity Taken

Frequency Taken

(6) Is there any known family history relating to kidney/cardiovascular disease? If yes, please describe:

Age

Cause of death,

History of kidney

History of heart disease

History of stroke?

(if living)

(at death)

if deceased:

disease?

or circulatory disorder?

r Yes r No

Mother

r Yes r No

Father

r Yes r No

Sister(s)

r Yes r No

Brother

Blood In The Urine (Hematuria) Questionnaire Page 2

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