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DIABETES

Definition: A metabolic disease where carbohydrate utilization is reduced and lipid and protein enhanced; it is caused by either a deficiency of insulin normally secreted by the pancreas or by resistance to the body's insulin. Onset under age 20 is considered juvenile onset . metabolic disease where carbohydrate utilization is reduced and lipid and protein enhanced; it is caused by either a deficiency of insulin normally secreted by the pancreas or by resistance to the body's insulin. Onset under age 20 is considered juvenile onset .

A. Date and age of onset?

B. Type(s) of treatment? Diet, oral medication, or insulin?

C. If insulin dependent, give the number of units taken, the types taken (ie: Regular, Lente, NPH, Humalog) and times of day taken? If oral medication(s) give dosage and type(s).

D. Has client ever had problems with eyes (Retinopathy), circulation, numbness or tingling in the hands and feet (Neuropathy), infections or kidney problems? If yes, give Date(s)?

E. Does proposed insured test his blood on a regular basis? If so, how often and what are the usual results?

F. Is client under good control? Has client ever been in a diabetic coma? If so, Date(s)?

G. How often does client visit doctor? Date of last visit?

H. Date and result of last fasting blood glucose and/or glycohemoglobin A₁C reading?

I. Answer ALL questions listed under
#1 General Risk Profile 

DRUG ABUSE

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. 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.

A. What type of Drug(s) used? Dosage or amount used?

B. How long has client abstained from drug use? Number of relapses if any? Dates?

C. Is Client currently a member of NA, CA, AA, or any other support group?

D. Did the client go through a formal treatment program? Was treatment on an Inpatient or Outpatient basis? Date(s)?

E. Was client ever treated for an overdose? Dates?

F. Was client ever treated for alcohol-related problems? If yes, give dates? Current alcohol use?

G. Family Situation?

H. Answer ALL questions listed under
#1 General Risk Profile 

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