Drug Abuse Questionnaire

Drug Abuse Questionnaire

SECTION I: AGENT INFORMATION
Full Name of Agent:
Agent's Phone Number
Agent's Fax Number
Agent's E-mail

SECTION II: CLIENT BACKGROUND INFORMATION
Client's Name
Date Of Birth:
Sex:	Male Female
Smoker:	Smoker Non-smoker
If history of smoking, date stopped?:
Occupation? (if not currently employed explain - ie: disabled, Social Security Disability Workman's Comp., etc.)
Type of product:
Face amount requested?
Premium Range Desired? (If replacement, list current premium and face amount)

SECTION III: CLIENT MEDICAL INFORMATION
Prior company action? (Name of company, rating, premium)
Type of medical impairment or other underwriting problem?
Date condition was first diagnosed?
Current height and weight? (If weight has changed in the last 12 months, please indicate)
Current blood pressure readings?
Name all medications currently being taken. Include dosage and frequency. (ie: 25mg. 2X per day)
Is client currently seeing a doctor for listed condition? Date of last visit?
Types and dates of surgery or hospital treatment?
Has any immediate relative (father, mother, sister, brother) died prior to age 60 of heart disease, diabetes complications, or cancer?
Any other medical history?

SECTION IV: DRUG ABUSE QUESTIONS
Definition: Any chemical substance that alters mood, perception, consciousness or body function. Pharmaceutical drugs prescribed by doctors for anxiety, depression, sleeplessness or other common problems can become abusive when recommended dosages are exceeded.
What type of Drug(s) used? Dosage or amount used?
How long has client abstained from drug use? Number of relapses if any? Dates?
Is Client currently a member of a drug addiction recovery group such as NA, CA, AA, or any other support group?
Did the client go through a formal treatment program? Was treatment on an Inpatient or Outpatient basis? Date(s)?
Was client ever treated for an overdose? Dates?
Was client ever treated for alcohol-related problems?
Current family status (ie: married, divorced, single, children, etc.)

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