Test Health Quiz

Full Legal Name:

Please enter your full legal name.

Confirm Email:

Please enter a valid email address.

Gender:

Please select your gender.

State:

Please enter your state.

Zipcode:

Please enter your zipcode.

Phone Number:

Please enter your phone number.

Date of Birth:

Please enter your date of birth.

How Much Coverage:

Please enter the coverage amount.

Have you ever smoked cigarettes?

Yes

No

Please select an option.

Have you ever used OTHER NICOTINE products?

Yes

No

Please select an option.

In the last 10 years have you used Marijuana for medical or recreational purposes?

Yes

No

Please select an option.

How Tall are you?

Please enter your height.

What do you weigh?

Please enter your weight.

Have you lost more than 10 pounds in the last 12 months?

Yes

No

Please select an option.

Any treatment for high blood pressure?

Yes

No

Please select an option.

Any treatment for elevated Cholesterol?

Yes

No

Please select an option.

Any Heart Problems, Irregular Heart Beat, or chest pain in the past?

Yes

No

Please select an option.

Any Past history of Stroke, Mini Stroke, or Blood Clots?

Yes

No

Please select an option.

History of Diabetes or Elevated Blood Sugar?

Yes

No

Please select an option.

Last A1C reading (if yes to Diabetes):

What Type of Treatment for Your Diabetes? (If yes To Diabetes):

Any form of Cancer or Tumors in your lifetime?

Yes

No

Please select an option.

Any issues with Asthma or Respiratory Ailments such as COPD?

Yes

No

Please select an option.

Has a Doctor ever advised you have a sleep study, or any History of Sleep Apnea?

Yes

No

Please select an option.

Past issues with Anxiety, Depression, or Nervous Disorder?

Yes

No

Please select an option.

Any History of Alcohol or Drug abuse?

Yes

No

Please select an option.

Ever diagnosed with Dementia/Alzheimers Disease or are you currently taking Donepezil (Aricept®), Rivastigmine (Exelon®), Galantamine (Razadyne®), Memantine (Namenda®)?

Yes

No

Please select an option.

In the past 5 years, have you had any lab test abnormalities with your liver or kidneys, or elevated (PSA if a male)?

Yes

No

Please select an option.

Any other Medications or treatments that you haven’t told me about?

Complete List Of Medications:

Please provide a complete list of medications.

Explanation to Any Yes Answers Above:

Please provide explanations for any yes answers.

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Agree

Disagree

Please select an option.

Health Quiz

Health and Lifestyle: