Dan Berry Insurance, Inc. - Health Questionnaire

54101 Ironwood Rd
South Bend, IN 46635
(574) 255.6222 Phone • ( 574) 255.6307 Fax
(574) 254-2630 Fax 2

Health Questionnaire All items are required.
Today's Date	(00/00/0000)
Name
Address
City		State
Zip
County
Work Phone	(000-000-0000)
Home Phone	(000-000-0000)
E-Mail
Do your currently have medical insurance?
Deductible	$
Height	(0" 00")
Weight	Lbs.
Date of Birth	(00/00/0000)
Occupation
Smoker
Medications (All medications must have name, dosage and times per day taken)
Health Conditions

SPOUSE
Name
Height	(0" 00")
Weight	Lbs.
Date of Birth	(00/00/0000)
Occupation
Smoker
Medications (All medications must have name, dosage and times per day taken)
Health Conditions

CHILDREN
Name	Date of Birth
Please list any medications taken by this child including the name of the medication, dosage, number of times taken per day as well as any health conditions.
Name	Date of Birth
Please list any medications taken by this child including the name of the medication, dosage, number of times taken per day as well as any health conditions.
Name	Date of Birth
Please list any medications taken by this child including the name of the medication, dosage, number of times taken per day as well as any health conditions.
General Comments or Questions

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