HEALTH INSURANCE QUESTIONNAIRE
First Name:
Last Name:
Age:
Address Line 1:
Address Line 2:
City:
County:
Post Code:
History of Hereditary Disease: Heart Asthma Arthritis
Exercise:
Diet:
Alcohol:
Smoking:
General Health:
Frequently Low Fat Light Non Smoker Light
Average Average Medium Light Average
Seldom High Fat Heavy Heavy Poor