HEALTH INSURANCE
Person Info
Health Evaluation
Finish
Let's start with the basic details
Name
Email
Address
City
State
Zip
Date Of Birth
Education
Occuption
Status
- Status -
Single
Married
Gender
- Gender -
Male
Female
Militory Experience
- Militory Experience -
Yes
No
1- Would you like to describe you health?
Good
Fair
Poor
2- Do you have any spacific health concerns? if yes,please list.
3- Have you had a medical examination within the past five year?
Yes
No
4- Are you under a doctor's care for any diagnosed condition?
Yes
No
5- Are you taking prescription medications?
Yes
No
6- What was your last B/P (blood pressure) reading.
7- Do you use tobacco in any form??
Yes
No
8- If yes, how much do you use?
9- Do you routinely participate in vigorous exercise for 20 minutes at least three times a week?
Yes
No
Thank you for taking our survey. Your response is very important to us.