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CLIENT INFORMATION
First Name
*
Last Name
*
Occupation
Smoker
Tobacco
Vape
Chew
Cigars
None
Residency Status
US Citizen
Permanent Resident
Gender
Male
Female
E.g. Gender
Date of Birth
Age
Height
Weight
Email Address
*
Phone Number
*
Appointment Date
Hours
Minutes
AM
PM
COMMON HEALTH QUESTIONS
Substance Use
Alcohol
Drug Abuse
DUI
Arrest
Status
Current
Past
Year
Additional Information
Mental Health
Anxiety
Bipoloar
Depression
PTSD
Year Diagnosed
Hospitalizations
Yes
No
Medications
Asthma
Mild
Seasonal
Moderate
Severe
Most Recent Attack
Hospitalizations
Yes
No
Medications
Diabetes Type
Type 1
Type 2
Other
Controlled With
Insulin
Oral Meds
Complications
None
Gout
Neuropathy
Year Diagnosed
Last A1C test
Medications
High Cholesterol
Yes
No
Latest Reading
Medications
Heart Attack
Yes
No
Hospitalizations
Yes
No
Treatment
Stints
Bypass
Most Recent Attack
Medications
Stroke
Major
Minor
Most Recent Stroke
Medications
High Blood Pressure
Yes
No
Latest Reading
Medications
Arthritis
Yes
No
Type
Rheumatoid
Osteoarthritis
Year Diagnosed
Medications
COPD
Yes
No
Type
Oxygen
No Oxygen
Cancer
Basal
Squamous
Metastatic
Type
Grade
Year Diagnosed
Treatment
Medications
Other Surgeries
Yes
No
Year Performed
Reason
Disability
Yes
No
Year Diagnosed
Collecting Disability
Yes
No
Employment
Working
Unable to Work
Sleep Apnea
Yes
No
Treatment
CPAP
No Treatment
Other Surgeries/Medical History
OTHER INFORMATION
Co Borrower
Yes
No
Name
Date of Birth
Main Concern/Reason for Inquiry
Mortgage Protection
Yes
No
Monthly Payment
Mortgage Term
15 Years
30 Years
Other
Other Insurance/Savings
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