Have you used any tobacco, nicotine, or marijuana products in the last 5 years? *

Have you ever been diagnosed or treated for lung disease: COPD, emphysema, or asthma? *

Do you require the use of any oxygen equipment or inhalers? *

Have you ever been diagnosed or treated for diabetes? *

Have you ever been diagnosed with cancer? *

Have you ever had kidney insufficiency, dialysis, cirrhosis, or hepatitis? *

Have you ever had a heart attack, bypass surgery, stent surgery, angina, pacemaker, defibrillator, stroke, seizure, or aneurysm? *

Have you ever been diagnosed with congestive heart failure? *

Have you been diagnosed with lupus, multiple sclerosis, Parkinson's, or ALS (Lou Gehrig's)? *

Have you ever been diagnosed or treated for depression, bipolar disorder, schizophrenia, Alzheimer's, or dementia? *

Have you been hospitalized overnight in the past 2 years? *

Are you currently in a hospital, nursing home, hospice, or receiving in-home care? *

Have you used illegal drugs, or been advised to have (or received) treatment or counseling for alcohol or drug use? *

In the past 2 years, have you had any medical test, procedure, or hospitalization that has not been completed, or for which you have not yet received the results? *

Have you been diagnosed with a terminal illness or given a life expectancy of 24 months or less? *

Have you ever been declined, postponed, or rated up for life insurance? *