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First Name:  Last Name: 
Street Address:  City:    Zip:
Day Phone:  ( ) - Ext Evening Phone:  ( ) - Ext
E-Mail: 
 
 For best accuracy, please answer each question truthfully.
When did you last use tobacco or nicotine?
Do you intend to fly as a Private Pilot? No Yes
Within the last 5 years, have you been convicted of either reckless
driving or driving while under the influence, received 3 or more
moving violations or had your license suspended/revoked? 		No Yes

Do you now have a Chapter 7 personal bankruptcy
filing that has not been discharged or an open Chapter 13
bankruptcy plan that does not yet have a repayment plan
established? 		No Yes
Do you recall your last blood pressure
reading?     		 systolic  
diastolic
    Are you taking blood pressure medication? No Yes
Do you recall what your last cholesterol level was?
    Are you taking cholesterol medication? No Yes
Any family (parents or siblings) diagnosed with cardiovascular
disease (heart disease or stroke) or cancer before age 60? 		No Yes
Have you ever been rated up or declined by any life insurance company? No Yes
Has any doctor recommended any medical test or procedure
that you have not yet completed? 		No Yes
For what medical conditions have you had symptoms or been diagnosed with over the past 12 years?
 Alzheimer's    Anxiety, ADD, ADHD or Depression    Artery (Coronary) Disease
 Asthma    Cancer (Other Than Skin)    Colitis or Ileitis
 COPD    Crohn's Disease    Diabetes
 Emphysema    Epilepsy    Heart Disease or Abnormal EKG
 Hepatitis or Liver Disease    HIV    Kidney Disease
 Leukemia    Melanoma    Mental Illness
 Mitral Valve Prolapse    Multiple Sclerosis    Parkinson's Disease
 Prostate Cancer    Rheumatoid Arthritis    Sleep Apnea
 Stroke    Vascular Disease    
Within the last 7 years, have you had any of the following conditions?
 Alcoholism    Cancer (Skin Only)    Drug Abuse or Addiction
 Gastric/Peptic Ulcers    Recurrent Kidney Stones    
Other
 
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