FE Health Quiz, Complete and Submit.
**This information is used to isolate proper rate class which will determine the best price and provider. Information IS NOT shared and is Confidential!! 
Email *
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Tell us a little about you. 
Full Legal Name *
Gender *
State  *
Zipcode *
Phone Number *
Date of Birth *
MM
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DD
/
YYYY
How Much Coverage *
Health and Lifestyle 
**Isolating proper rate class will determine best price and provider.
Have you ever smoked cigarettes? *
How long ago did you stop smoking? (Approx years)
Have you ever used OTHER NICOTINE products? *
In the last 10 years have you used Marijuana for medical or recreational purposes?    *
If yes to Medical MJ use, please explain the condition it is treating.
How Tall are you?  *
What do you weigh? *
Have you lost more than 10 pounds in the last 12 months? *
Are you currently bedridden or confined to any hospital, nursing home, long-term care facility or skilled nursing facility; or receiving or been advised to receive care in a nursing home, hospice care, or home health care?
 *
Any treatment for high blood pressure? *
Any treatment for elevated Cholesterol? *
Any Heart Problems, Irregular Heart Beat, or chest pain in the past? *
If yes, what type of heart problems? And Approx date of event, (MM/YYYY)
Any Past history of Stroke, Mini Stroke, or Blood Clots? *
If yes to Stroke/TIA, when did the stroke/TIA take place (MM/YYYY)?
History of Diabetes or Elevated Blood Sugar? *
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? *
If yes to cancer, what type? When was your last treatment (MM/YYYY)?
Since last treatment, Are you.....
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Any issues with Asthma or Respiratory Ailments such as COPD? *
Has a Doctor ever advised you have a sleep study, or any History of Sleep Apnea? *
Past issues with Anxiety, Depression, or Nervous Disorder? *
Any History of Alcohol or Drug abuse? *
Ever diagnosed with ARC, AIDS, or HIV? *
Ever diagnosed with Dementia/Alzheimers Disease or are you currently taking  Donepezil (Aricept®),  Rivastigmine (Exelon®),  Galantamine (Razadyne®),  Memantine (Namenda®)? *
In the past 5 years, have you had any lab test abnormalities with your liver or kidneys, or elevated (PSA if a male)?
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Any other Medications or treatments that you haven't told me about?
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Complete List Of Medications *
Explanation to Any Yes Answers Above *
Avoid Catostrophic Financial Burdens Due To Unforseen Circumstances

Do you have any Family History of:
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Required
Would you like to hear about how you can get financial relief and a lump sum payout of $5000-$100000 upon diagnosis of any of the above health impairments
 *
For possible Household Discounts, Which Medicare Plan Do You Have
 *
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