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Coverage Amount
How much coverage do I need?
If you are a family breadwinner with dependents, financial planners suggest carrying ten times your annual income. If you are a non-working caregiver at home, we suggest your choice of $150,000 to $500,000. If you are looking for burial coverage only, we suggest $5,000 to $25,000. Click here to access the Life Happens life insurance needs calculator.
    
Coverage Estimator Tool
ZIP & State of Residence   
Birth Date
(Ages 14 Days - 90 Years)
Gender  Male    Female
Any tobacco, nicotine, marijuana,
vape or tobacco substitute use?
Why do life insurers ask about this?
Nicotine use of any kind, including marijuana use, is looked at very closely by all life insurers. Smoking, chewing, inhaling in a vaporized form, consuming in edible products, and wearing a patch on the skin, all constitute use of these products. Non-admittance of marijuana use can result in a decline. Sources of information the insurer may use include: statements made on your application, telephone interviews, your paramed exam results (if one is required), your outside medical records and your Medical Information Bureau (MIB) profile. If you currently use marijuana AND any product containing tobacco or nicotine, please select the response that most closely describes your tobacco or nicotine use. Always be 100% honest when you answer tobacco use questions to ensure accurate quotes. Remember, a false statement on an application for insurance could void your coverage.
Height & Weight
 Height
 Weight (with clothes on)
Why does the life insurance company need to know your actual weight?
Weight (with clothes on) is a key rating factor with all life insurance companies. Please give an honest answer here so that you can receive accurate rate quotes. And keep in mind that the paramed examiner who visits you will be carrying a portable scale, so be honest here.
  
Next
Non-medical questions that can affect your premium
Did you think that life insurance companies look only at your health history? Not true. Today, life insurance companies look just as closely at many non-medical aspects as they do at your health. Items looked at very closely include disability, receiving government benefits, open bankruptcy, U.S. citizen status, hazardous activities such as mountain climbing or racing, intended foreign travel to dangerous countries, private pilot intentions, scuba diving habits, driving and criminal record status. In order to receive an accurate rate quote, always be honest in your answers to these questions.
Are you now receiving disability payments from any source?
No   Yes
Are you now receiving any form of government assistance such as Food Stamps, WIC or Medicaid?
No   Yes
In the last 5 years have you had any overdue loans, bankruptcy, judgements, tax liens, collections or debt repayment plans established?
No   Yes
Do you now (or have you in the last year) worked at a paying job (employed or self-employed) 20 or more hours per week?
No   Yes
Occupation:
Annual Income Range:
Are you a U.S. Citizen?
No   Yes
Do you intend to participate in commercial aviation, private aviation, scuba diving, motorized racing, mountaineering or rock climbing, travel to any country on the U.S. State Department's Travel Warnings list, or any other potentially hazardous activities?
No   Yes
Within the last 5 years, have you been convicted of either reckless driving or driving while under the influence, received 3 or more moving violations or had your license suspended or revoked?
No   Yes
Have you ever had a professional license revoked, had a criminal convictions or law enforcement infraction of any kind or been on parole or probation?
No   Yes
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Previous
Family & Health questions that can affect your premium
Have you ever had a professional license revoked, had a criminal convictions or law enforcement infraction of any kind or been on parole or probation?
No   Yes
Next
Previous
Family & Health questions that can affect your premium
Have you ever been rated up or declined by any life insurance company?
No   Yes
Have any of your parents or siblings (biological only), prior to age 60, been diagnosed with or died from:
• Cardiovascular, heart or coronary artery disease, or stroke? No   Yes
• Cancer, other than basal or squamous cell skin cancer? No   Yes
Excluding cosmetic surgery, has any doctor recommended any medical test or procedure that you have not yet completed?
No   Yes
Have you taken any prescription medications (including from a dentist) in the past 3 years or been diagnosed with any medical condition in the last 10 years?
No   Yes
Recurrent Kidney Stones Questionnaire
Year of diagnosis:
Date of most recent attack:
How many episodes have you had?
How many total stones have there been?
Have you ever been hospitalized for this condition? No  Yes
Has any special testing been done, such as kidney function tests? No  Yes
Please list the type of treatment received:
Describe how well this condition is under control or if it restricts normal life in any way:
For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?
 AFIB (Atrial Fibrillation)  
 Alzheimer's  
 Artery (Coronary) Disease
 Arthritis (Psoriatic or Rheumatoid)  
 Cancer  
 Colitis or Ileitis
 COPD  
 Crohn's Disease  
 Depression or Mental Illness
 Diabetes  
 Emphysema  
 Epilepsy
 Fibromyalgia  
 Gout  
 Heart Disease or Abnormal EKG
 Hepatitis or Liver Disease  
 HIV  
 Hypothyroidism (low thyroid)
 Kidney Disease  
 Lupus  
 Mitral Valve Prolapse
For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?
 AFIB (Atrial Fibrillation)  
 Alzheimer's  
 Artery (Coronary) Disease
 Arthritis (Psoriatic or Rheumatoid)  
 Cancer  
 Colitis or Ileitis
 COPD  
 Crohn's Disease  
 Depression or Mental Illness
 Diabetes  
 Emphysema  
 Epilepsy
 Fibromyalgia  
 Gout  
 Heart Disease or Abnormal EKG
 Hepatitis or Liver Disease  
 HIV  
 Hypothyroidism (low thyroid)
 Kidney Disease  
 Lupus  
 Mitral Valve Prolapse
 Multiple Sclerosis  
 Pain (Chronic & Ongoing)  
 Parkinson's Disease
 Prostate Issues (no cancer)  
 Sarcoidosis  
 Sleep Apnea
 Stroke  
 Vascular Disease  
 
Psoriatic or Rheumatoid Arthritis Questionnaire
Year of diagnosis:
Age at diagnosis:
Have you ever had any of the following occurrences or symptoms?
Weight Loss Fever
Low Blood Counts Heart Disease
Lung Disease Liver Enzyme Abnormality
Kidney Disease Other: 
Which joints are involved?
Describe present symptoms:
List medications for this condition:
Have you ever taken steroids, gold, or immunosuppresive therapy? No  Yes
Please check functional ability:
Fully Active Sedentary
Uses Walker, Cane, etc. Uses Wheelchair
Describe how well this condition is under control or if it restricts normal life in any way:
Vascular / Heart Disease or Abnormal EKG Questionnaire
List history of vascular or heart disease (i.e. what diagnosis?)
Year of diagnosis:
What was your age when diagnosed with this condition?
Ever had any of the following occurrences or symptoms?
Chest Pain Trouble Breathing
Describe present symptoms:
List medications for this condition:
Have you ever taken steroids, gold, or immunosuppresive therapy? No  Yes
Please check functional ability:
Fully Active Sedentary
Uses Walker, Cane, etc. Uses Wheelchair
Describe how well this condition is under control or if it restricts normal life in any way:
Vascular / Heart Disease or Abnormal EKG Questionnaire
Date:
List history of vascular or heart disease (i.e. what diagnosis?)
Year of diagnosis:
What was your age when diagnosed with this condition?
Ever had any of the following occurrences or symptoms?
Chest Pain Trouble Breathing
Heart Failure Heart Palpitations
Atrial Fibrillation/Flutter Abnormal EKG
Enlarged Heart  
Have you ever smoked? No  Yes
Have any of the following tests been done or recommended?
Echocardiogram
Exercise Treadmill or Thallium
Stress Test
Other
Ever had any of the following procedures done or recommended?
Cardiac Catheterization
Coronary Angioplasty
Coronary Artery Bypass Graft
Coronary Defibrillator
Coronary Stent
Coronary Pacemaker
Valve Surgery
Are you taking medications for the condition (including aspirin)? No  Yes
Coronary Angioplasty
Coronary Artery Bypass Graft
Coronary Defibrillator
Coronary Stent
Coronary Pacemaker
Valve Surgery
Are you taking medications for the condition (including aspirin)? No  Yes
Are there any restrictions on daily activities? No  Yes
What is date and result of last checkup with any heart specialist for this condition?
Note: Underwriters typically require current (within last 24 months) cardiac follow-up on your part and compliance with your doctor's recommendations given that cardiac-related death is #1 cause of death in the U.S. All cardiac and cardiac-related medical records are looked at very closely by the life underwriter and compliance with your doctor's instructions and regular checkups are critical to getting a good life insurance offer.
Are you in compliance with your doctor's recommendations? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Breast Cancer Questionnaire
What was the stage of the cancer?
What was the size of the tumor?
Were lymph nodes involved? No  Yes
At what age was the diagnosis made?
How was the cancer treated?
 Removal of tumor only    
 Lumpectomy or wide excision    
 Mastectomy    
 Radiation therapy    
 Chemotherapy    
 Hormone therapy
Date treatment was completed:
At what age was the diagnosis made?
How was the cancer treated?
 Removal of tumor only    
 Lumpectomy or wide excision    
 Mastectomy    
 Radiation therapy    
 Chemotherapy    
 Hormone therapy
Date treatment was completed:
Date cancer was declared "in remission":
Is there a history of breast cancer in other immediate family members? No    Yes
List any medications being taken now for this condition:
Any evidence of recurrence since treatment completed? No  Yes
Date and results of last mammogram:
Describe how well this condition is under control or if it restricts normal life in any way:
Cervical Cancer Questionnaire
What was the stage of the cancer?
At what age was the diagnosis made?
How was the cancer treated?
 Total Hysterectomy    
 Cone Surgery    
 Radiation Therapy    
 Chemotherapy    
When was treatment completed?
Cervical Cancer Questionnaire
What was the stage of the cancer?
At what age was the diagnosis made?
How was the cancer treated?
 Total Hysterectomy    
 Cone Surgery    
 Radiation Therapy    
 Chemotherapy    
When was treatment completed?
Have you had a negative papsmear in the last 12 months? No    Yes
Date and results of last doctor visit for this condition:
Did the cancer metastasize? No    Yes
Date cancer was declared "in remission":
Any evidence of recurrence since treatment completed? No    Yes
List all medications being taken now for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Colon Cancer Questionnaire
What was the stage of the cancer?
At what age was the diagnosis made?
Did you have any adenomatous polyps prior to age 50? No    Yes
How many polyps have you had in the last 5 years?
How was the cancer treated? Surgery        Surgery plus radiation and/or chemotherapy
List all medications being taken now for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Colon Cancer Questionnaire
What was the stage of the cancer?
At what age was the diagnosis made?
Did you have any adenomatous polyps prior to age 50? No    Yes
How many polyps have you had in the last 5 years?
How was the cancer treated? Surgery        Surgery plus radiation and/or chemotherapy
When was treatment completed?
When was your last colonoscopy?
Do you have your CEA levels tested regularly? No    Yes
Is there a history of colon cancer in other immediate family members? No    Yes
Date and results of last doctor visit for this condition:
Did the cancer metastasize? No    Yes
Date cancer was declared "in remission":
Any evidence of recurrence since treatment completed? y>
Do you have your CEA levels tested regularly? No    Yes
Is there a history of colon cancer in other immediate family members? No    Yes
Date and results of last doctor visit for this condition:
Did the cancer metastasize? No    Yes
Date cancer was declared "in remission":
Any evidence of recurrence since treatment completed? No    Yes
List all medications being taken now for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Leukemia Questionnaire
Please select type of leukemia:
 Chronic Lymphocytic Leukemia  Hairy Cell Leukemia
Melanoma Questionnaire
Year of diagnosis:
Please note where the melanoma was located:
Which type of melanoma were you diagnosed with?
Superficial Spreading Melanoma Nodular Melanoma
Lentigo Maligna Melanoma Acral Lentiginous Melanoma
Other: 
For malignant melanoma only. Please provide all items:
Stage (if available)
Ulcerated? No  Yes
Clark's Level
Thickness in mm
Any positive Lymph Node? No  Yes
Has the cancer metastasized (spread) beyond the skin? No  Yes
Has there been any evidence of recurrence? No  Yes
List all medications being taken (include inhalers):
Describe how well this condition is under control or if it restricts normal life in any way:
Prostate Cancer Questionnaire
Acral Lentiginous Melanoma
Other: 
For malignant melanoma only. Please provide all items:
Stage (if available)
Ulcerated? No  Yes
Clark's Level
Thickness in mm
Any positive Lymph Node? No  Yes
Has the cancer metastasized (spread) beyond the skin? No  Yes
Has there been any evidence of recurrence? No  Yes
List all medications being taken (include inhalers):
Describe how well this condition is under control or if it restricts normal life in any way:
Prostate Cancer Questionnaire
What stage was the cancer?
What was the PSA level prior to treatment?
What was the Gleason score (scale of 1-10)?
Date of biopsy:
How was the cancer treated?
 Observation only    
 Radical Prostatectomy    
 TURP (Transurethral Prostatectomy)    
 Radiation Therapy (Seed implant or external beam radiation)    
 Hormone therapy    
Date treatment completed:
When was the most recent PSA test?
ated_Hormone">  Hormone therapy    
Date treatment completed:
When was the most recent PSA test?
What was the result of the most recent PSA test? Less than 1  1 or higher
Has there been any evidence of recurrence? No  Yes
List medications being taken now for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Skin Cancer Questionnaire
Year of diagnosis:
What type of skin cancer was diagnosed?
Basal cell carcinoma Squamous cell carcinoma
Please note where the skin cancer was located:
Has the cancer metastasized (spread) beyond the skin? No  Yes
Has there been any evidence of recurrence? No  Yes
Are you on any medications? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Testicular Cancer Questionnaire
What was the stage of the cancer?
At what age was the diagnosis made?
How was the cancer treated? Surgery        Surgery plus radiation and/or chemotherapy
When was treatment completed?
Are you on any medications? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Testicular Cancer Questionnaire
What was the stage of the cancer?
At what age was the diagnosis made?
How was the cancer treated? Surgery        Surgery plus radiation and/or chemotherapy
When was treatment completed?
What type of testicular cancer was it? Seminoma        Nonseminoma
Do you have regular annual follow-ups? No    Yes
Date and results of last doctor visit for this condition:
Did the cancer metastasize? No    Yes
Date cancer was declared "in remission":
Any evidence of recurrence since treatment completed? No    Yes
List all medications being taken now for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Thyroid Cancer Questionnaire
What was the stage of the cancer?
At what age was the diagnosis made?
Any evidence of recurrence since treatment completed? No    Yes
List all medications being taken now for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Thyroid Cancer Questionnaire
What was the stage of the cancer?
At what age was the diagnosis made?
What type of thyroid cancer was it?
How was the thyroid cancer treated? (Check all that apply)
 Lobectomy    
 Thyroidectomy    
 Radioactive Iodine    
 Chemotherapy    
 Thyroid Hormone Therapy    
 External Beam Radiation    
 Targeted Drug Therapy
When was treatment completed?
Are you compliant with follow-up imaging, blood tests and physical exams? No    Yes
Do you have a known family history of medullary thyroid cancer? No    Yes
Date and results of last doctor visit for this condition:
Did the cancer metastasize? No    Yes
1953
Date cancer was declared "in remission":
Are you compliant with follow-up imaging, blood tests and physical exams? No    Yes
Do you have a known family history of medullary thyroid cancer? No    Yes
Date and results of last doctor visit for this condition:
Did the cancer metastasize? No    Yes
Date cancer was declared "in remission":
Any evidence of recurrence since treatment completed? No    Yes
List all medications being taken now for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Cancer Questionnaire
Tissue of origin and type of cancer diagnosis (e.g. liver, etc.)
Year of diagnosis:
Grade, stage, and/or tumor size:
Did the cancer metastasize? No  Yes
How was the cancer treated?
Observation only
Surgery
Chemotherapy
Radiation therapy
Hormone therapy
Other: Date completed:
Date cancer was declared "in remission":
Any evidence of recurrence since treatment completed? No  Yes
List all medications being taken now for this condition:
Date and results of last doctor visit for this condition:
Describe how well this condition i
Surgery
Chemotherapy
Radiation therapy
Hormone therapy
Other: Date completed:
Date cancer was declared "in remission":
Any evidence of recurrence since treatment completed? No  Yes
List all medications being taken now for this condition:
Date and results of last doctor visit for this condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Colitis / Ileitis Questionnaire
Year of diagnosis:
Please note the type of inflammatory bowel disease present:
 Chronic Ulcerative Colitis  Chronic Proctitis (inflammation in rectum only)
Are you on any medications? No  Yes
Please check if you have had:
hospitalizations for this disorder (list dates) List Dates: 
surgery for this disorder (list dates) List Dates: 
colonoscopy (list dates of most recent) List Dates: 
Describe how well this condition is under control or if it restricts normal life in any way:
COPD Questionnaire
Year of diagnosis:
Have you ever had any of the following occurrences or symptoms?
Chronic Bronchitis Emphysema
Restrictive Lung Disease Asthma
List all medications being taken (include inhalers):
Have you ever had any abnormalities associated with ECG or x-ray? No  Yes
Have pulmonary function tests (a breathing test) ever been done? No  Yes
Have you ever been hospitalized for this condition? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Crohn's Disease Questionnaire "100%">
COPD Questionnaire
Year of diagnosis:
Have you ever had any of the following occurrences or symptoms?
Chronic Bronchitis Emphysema
Restrictive Lung Disease Asthma
List all medications being taken (include inhalers):
Have you ever had any abnormalities associated with ECG or x-ray? No  Yes
Have pulmonary function tests (a breathing test) ever been done? No  Yes
Have you ever been hospitalized for this condition? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Crohn's Disease Questionnaire
Year of diagnosis:
Have you ever had any of the following occurrences or symptoms?
Hospitalizations for this disorder Date(s):
Surgery for this disorder Date(s):
Colonoscopy Date(s):
List all medications being taken (prescription and non-prescription):
Describe how well this condition is under control or if it restricts normal life in any way:
Anxiety, Depression and Mental Illness Questionnaire
on>
What is the specific diagnosis (e.g. depression, anxiety, bipolar disorder, anorexia, etc.)?
When was the condition diagnosed?
Are you now taking any medication for this condition? No  Yes
Are you seeing, or have you seen a therapist for this condition? No  Yes
Have you received, or are you receiving disability benefits for this condition? No  Yes
Have you ever been hospitalized for this condition? No  Yes
Have you had accidents at work or while driving? No  Yes
Have you lost time from work because of this condition? No  Yes
Current daily dosage:
Are you seeing, or have you seen a therapist for this condition? No  Yes
Have you received, or are you receiving disability benefits for this condition? No  Yes
Have you ever been hospitalized for this condition? No  Yes
Have you had accidents at work or while driving? No  Yes
Have you lost time from work because of this condition? No  Yes
Do you have a history of substance abuse (alcohol or drug)? No  Yes
Any history of suicide attempt or ideation? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Diabetes Questionnaire
What type of Diabetes?
Emphysema Questionnaire
Year of diagnosis:
Type of lung disease:
Chronic Bronchitis Emphysema
Restrictive Lung Disease Asthma
Have you ever been hospitalized for this condition? No  Yes
Are you on any medications (include inhalers)? No  Yes
Have pulmonary function tests (a breathing test) ever been done? No  Yes
Do you have any abnormalities on an ECG or x-ray? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Epilepsy Questionnaire
Year of diagnosis:
Please provide date of most recent episode:
Please provide number of episodes per year:
Please note type of seizure:
Are you on any medications (include inhalers)? No  Yes
Have pulmonary function tests (a breathing test) ever been done? No  Yes
Do you have any abnormalities on an ECG or x-ray? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Epilepsy Questionnaire
Year of diagnosis:
Please provide date of most recent episode:
Please provide number of episodes per year:
Please note type of seizure:
Complex/Partial Seizure Tonic-Clonic Seizure
Absense Seizure Myoclonic Seizure
Are you on any medications? No  Yes
Have you been hospitalized for treatment of epilepsy? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Chronic Pain / Fibromyalgia Questionnaire
Year of diagnosis:
Is the pain localized or widespread?
Are you taking any medication? No  Yes
Do you have any disabilities or physical impairments? No  Yes
Do you have a history of mental illness? No  Yes
Do you drink alcohol? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Gout Questionnaire
Year of diagnosis:
What is the date of your last attack?
How frequent are attacks?
Are you taking any medication? No  Yes
Do you have a history of mental illness? No  Yes
Do you drink alcohol? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Gout Questionnaire
Year of diagnosis:
What is the date of your last attack?
How frequent are attacks?
Are you taking any medication? No  Yes
Are there joint deformities? No  Yes
Do you have any physical impairments?
Do you drink alcohol? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Hepatitis/Liver Disease Questionnaire
Year of diagnosis:
What is the diagnosis?
Hepatitis A Hepatitis B, resolved
Hepatitis B, carrier or chronic infection Hepatitis C (non-A/non-B)
Jaundice Fatty Liver
Cirrhosis Other: 
Have any of the following tests been done?
Liver Enzyme Tests Date:
AST/SGOT Result:
ALT/SGPT Result:
GGPT Result:
Liver ultrasound Normal Abnormal
CT scan/MRI Normal Abnormal
Liver Biopsy Normal Abnormal
Do you drink alcohol? No  Yes
What type(s) of treatment have been/are being done?
Observation  
Medication
Surgery
Have you been treated with interferon or anti-viral drugs? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Hypothyroidism Questionnaire
Year of diagnosis:
Has an ultrasound or radioactive scan of the thyroid been done? No  Yes
Are you taking any medications? No  Yes
Are your thyroid levels normal? No  Yes
Describe how well this condition is under control or if it restricts normal life in any way:
Kidney Disease Questionnaire
Please select type:
 Glomerulonephritis  Kidney Transplant
 Proteinuria  Polycystic Kidney Disease
Lupus Questionnaire
Year of diagnosis:
Which type of lupus?
Systemic Lupus Erythematosus Discoid Lupus
Drug Induced Lupus  
Are you taking any medication for this condition? No  Yes
Are you currently receiving any other treatment for this condition? No  Yes
Is the lupus active? No  Yes
Please check if you have any of the following:
Low blood counts Lung involvement
Proteinuria High blood pressure
Neurologic disorder Heart involvement (pericarditis)
Renal insufficiency or failure  
Describe how well this condition is under control or if it restricts normal life in any way:
Mitral Valve Prolapse Questionnaire
Year of diagnosis:
How long has this abnormality been present?
Have you ever had any of the following occurrences or symptoms?
Chest Pain Palpitations
Trouble Breathing Dizziness
Is the MVP associated with regurgitation? No  Yes
Is there a history of any other heart disease in addition to the mitral valve prolapse (problems with other valves, coronary artery disease, etc.)? No  Yes
Has an echocardiogram (ultrasound of the heart) been done? No  Yes
Is there a murmur? No  Yes
List all medications being taken now for any condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Multiple Sclerosis Questionnaire
Year of diagnosis:
Please indicate the number of episodes and date of last episode:
Are you on any medications? No  Yes
Please note current neurologic status and/or symptoms.
normal minimal residual impairment
moderate residual impairment severe residual impairment
Please provide all MRI brain scan reports:
Describe how well this condition is under control or if it restricts normal life in any way:
Parkinson's Disease Questionnaire
Year of diagnosis:
Please note the functional stage of you currently:
Stage I unilateral involvement
Stage II bilateral involvement but normal stance
Stage III bilateral involvement with mild postural imbalance but able to lead an independent life
Stage IV bilateral involvement with postural instability, requires substantial help
Stage V severe disease; restricted to bed or wheelchair
Has there been any evidence of progression? No  Yes
Has an echocardiogram (ultrasound of the heart) been done? No  Yes
Is there a murmur? No  Yes
List all medications being taken now for any condition:
Describe how well this condition is under control or if it restricts normal life in any way:
Multiple Sclerosis Questionnaire
Year of diagnosis:
Please indicate the number of episodes and date of last episode:
Are you on any medications? No  Yes
Please note current neurologic status and/or symptoms.
normal minimal residual impairment
moderate residual impairment