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    Pontos SECTION 1 Please complete all questions below. Omitted information will cause delays. In this se ‘whom insurance is being requested. For questions 5 through 124, for “yes” answers, p “you” and “your” refers to the person for e provide full details in Section 2. 1. Members height feet___inches Member's weight pounds Member 2. Are you now ona det preseibed by a physician or other health care provider? ves Ono 3. Are you now pregnant? I "yes,” what is your cue date (monthidayyear)? Ove O No 4. Are you now, or have you in the past 2yeats, used tobacco in ay form? Yes O No 5. Inthe past 5 years, have you eceved medical reatment or counseling by a physician or other health care provider fo, orbeen | Cl Yes O No advised by a physician or other heath care provider o discontinue, the use of lechol or prescribed or non-prescibed drugs? 6. Inthe past 5 years, have you been convicted f criving while intoxicated or under the influence of alcohol andor any drug? Ove O Wo I-yes’, specity"éte(s) of convction(s) (month day/ear) 7. Have you had any application for ie, acidental death and dismemberment or csabiliy insurance declined, postponed, Ove O No withdrawn ated, modified, or issued ater than as applied for? 8. Are you now receiving or applying for any disability benef, including workers’ compensation? Ces O Wo 9. Have you been Hospitalized 2s defined below (not inclucing wel-baby devery) inthe past 90 days? O ves Oo Hospitalized means admission for inpationt care ina hospital receipt of care ina hospoe tacit, intermediate care acy, long term care ail; or receipt othe following treatment wherever performed: cheratherap, radiation therapy or dialysis 10. Have you ever been diagnosed or treated by a physician or other health cae provider for Azquired Immunodeticiency ves O No ‘Syndrome (AIDS) of AIDS Related Complex (ARC)? 41. Inthe past 5 years, have you been ciagnosed, treated or given medical advice bya physician or ther healtn care provider yes O No for high blood pressure? 12. Have you ever been diagnosed, treated or given medical advice by a physician or other health care provider fr: 2. cata o cardiovascular csorde? Oye Ono B, stoke or relator disrder suchas peripheral ary disease)? Ove Ono 6. cance, Hodgkins dsese, phoma or tumors? Ove Ono d. anemia, leukemia or other blood disorder? O Yes 0 No e. diabetes? O Yves O No Member: Your age at diagnosis?: OF Check if insulin treated {- asthma, COPD, emphysema or othe ung disease? Oye Ono 4. ulcers, siomach, pals or other liver disorder? Gye Ono h. colitis, Crohn's, diverticulitis or other intestinal disorder? OYes O No i,_ memory loss? Oves ONo i. epilepsy, paralysis, seizures, dizziness or other neurological disorder? O Yes O No ‘Member: Specify date of last seizure (month/year) Indicate type K.Epsten-Ba, cron fatigue syntome or fhromyalgia? Gyes Ono |. multiple sclerosis, ALS or muscular dystrophy? Oves ONo lupus, sekroderma, aut immune disease or connective tissue disorder? Ove Ono 1. artis? osteoarthritis Cl heunatoid CO otertype Os Ono 0, back, neck, knee, spinal, joint or other musculoskeletal disorder (such as herniated disc; back pain; cervical spondylosis; O Yes O No ‘meniscal, cartilage or ligament tears or injuries; hip fracture; or tendonitis)? p. carpal tunnel syndrome? Oves ONo q. kidney, urinary tract or prostate disorder? O ves ONo 1 thyroid or other gland disorder? OYes ONo ‘8, mental, anxiely, depression, attempted suicide or nervous disorder? OYves ONo 1. sleep apnea? Oye Ono

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