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Health Analyzer

Your Health Analyzer

A chance to know your very best options
Have you ever been treated for and/or taken medication for any of the following?:
  • Alcohol or Substance Abuse
  • Asthma
  • Blood Disorder
  • Cancer
  • COPD/Emphysema
  • Crohn’s Disease/Colitis
  • Dementia/Memory Loss
  • Depression/Anxiety/ ADD/ADHD
  • Diabetes
  • Heart Issue
  • Hepatitis
  • HIV/AIDS
  • Kidney Disorder
  • Lupus
  • Seizures
  • Sleep Apnea
  • Stroke/TIA
Contact Us Directly
Due to your selected options you will need to discuss your quote with us directly. Please enter your information below and we will contact you shortly.
First:
Last:
E-mail:
Phone:
Please enter comments as to your current condition(s):
Smoking / Tobacco Use
Have you EVER smoked or used:
Do You Have High Blood Pressure?: TODO: YES / NO
Have you ever been treated for or taken medication for high blood pressure?
What is your systolic pressure?
What is your diastolic pressure?
Cholesterol Treatment or Medication?
Have you ever been treated for or taken medication for high cholesterol?
Cholesterol level?
HDL ratio?
Driving - If You Have a License:
Have you ever been convicted of drunken driving (DUI/DWI)?
Have you ever been convicted of reckless driving?
Has your license ever been revoked or suspended?
Have you ever had more than one accident?
Please indicate the total number of moving violations/tickets (ie. not parking tickets) that you have received in each of the last time periods:
during the last 6 months:
during the last year, more than 6 months:
during the last 2 years, more than 1 year:
during the last 3 years, more than 2 years:
during the last 5 years, more than 3 years:
Family history of cancer or heart disease
Family related deaths:
Please indicate the total number of family members (parents or siblings) who have died from cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:
Family related occurrence of disease:
Not including those who died, please indicate the total number of family members (parents or siblings) who have contracted cardiovascular disease (heart attacks and strokes), cancer, diabetes or kidney disease before the age of 70:
Alcohol or Drug Abuse: TODO: add / yes / no
Alcohol Abuse?
If yes, the number of years since treatment:
Drug Abuse?
If yes, the number of years since treatment: