Preliminary Health Inquiry

Family History

Father:

Age if Living

Health Status

Age at Death

Cause of Death

Mother:

Age if Living

Health Status

Age at Death

Cause of Death

Sibling:

Age if Living

Health Status

Age at Death

Cause of Death

Sibling:

Age if Living

Health Status

Age at Death

Cause of Death

Foreign Travel / Nationals

Provide City, Country, Date, Duration, and Purpose of Any Travel Outside of the United States in the Past 5 Years:(Required)

(If not applicable, type N/A)

Provide City, Country, Date, Duration, and Purpose of Any Future Travel Outside of the United States:(Required)

(If not applicable, type N/A)

Country of Birth(Required)

State of Birth(Required)

Are you a U.S. Citizen?(Required)

If Not a U.S. Citizen, Please Complete the Following:

ID Type(Required)

Green Card Number(Required)

Green Card Expiration Date(Required)

Visa Number(Required)

Visa Expiration Date(Required)

Where is Your Current Citizenship?(Required)

Do You Plan to Apply for U.S. Citizenship in the Future?(Required)

If yes, when?(Required)

Avocation

Have you engaged in, or plan to engage in, any of the following: Aerial Sports, Scuba Diving, Aviation, Racing, Climbing, etc.?(Required)

If yes, please provide specific details for each activity, frequency, and dates:(Required)

Driving / Criminal History

Have you ever been arrested, convicted, or imprisoned for a felony and/or currently awaiting trial for any crime and/or felony?(Required)

If yes, please provide details of violation and dates:(Required)

Have you ever been cited for a DWI / DUI?(Required)

If yes, please provide details of violation and dates:(Required)

Have you been cited for any other traffic violations/moving violations, been in an accident or had your driver's license revoked within the past 5 years?(Required)

If yes, please provide specific violation and dates they occurred:(Required)

Tobacco / Alcohol Usage

Medical History

Family History

Foreign Travel / Nationals

If Not a U.S. Citizen, Please Complete the Following:

Avocation

Driving / Criminal History

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