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Multiple Sclerosis Questioner
Please complete all required information for a speedy quote. Thank you
Agent  Information:

Agent Name  

Address

City  

State Zip  

Email Address  

Phone   Fax  

Life License  

State Exp. Date  

Broker / Dealer  

Your client:

Name

D.O.B. Gender

HT   WT   STATE

Amount Required $

Max. Annual Premium $

Type of Insurance Perm.   Term Year's  Level

Tobacco Use:
Pipe
Cigar Chewing Cigarettes


If Replacing current annual premium?

Last Life Insurance App. year:

Company:

Action:

Requested Illustration:

1.
DATE MULTIPLE SCLEROSIS WAS DIAGNOSED

2. IS MULTIPLE SCLEROSIS ACTIVE? IF YES, 
WHAT IS THE DATE OF THE LAST ATTACK?

3. WHAT IS THE DEGREE OF SEVERITY OF MULTIPLE SCLEROSIS?
MILD - TOTAL 2 TO 4, MILD EXACERBATION WITH NO RESIDUALS

MODERATE - SLOWLY PROGRESSIVE, 1 OR 2 ATTACKS PER YEAR WITH RECOVERY BETWEEN ATTACKS, SOME MODERATE RESIDUALS, SUCH AS CANE USE

SEVERE - PROGRESSIVE, MORE THAN 2 ATTACKS PER YEAR, WHEEL CHAIR CONFINEMENT, BEDRIDDEN

RAPIDLY PROGRESSIVE SYMPTOMS

4. CURRENT SYMPTOMS, (CHECK ALL THAT HAVE OCCURRED OVER THE PAST TWO YEARS):
VISUAL DIFFICULTIES
NUMBNESS
WEAKNESS OR FATIGUE
IMPAIRED SWALLOWING
FREQUENT BLADDER INFECTIONS
BOWL CONTROL DIFFICULTIES
USE OF CANE
USE OF WHEEL CHAIR
DIFFICULTY WITH SPEECH

5. DATE OF CLIENT'S LAST VISIT TO A PHYSICIAN:

6. LIST THE LAST CHOLESTEROL READING, IF KNOWN:
HDL RATIO

7. LIST THE LAST BLOOD PRESSURE READING, IF KNOW:
SYSTOLIC DIASTOLIC

8. CLIENT'S OCCUPATION

9. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
IF YES, PLEASE DETAIL

10. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
IF YES, PLEASE DETAIL

11. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH:

    

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