Diabetes

Diabetes Mellitus

Diabetes Mellitus is a group of metabolic disorders characterized by chronic hyperglycemia from insulin deficiency or resistance, or both.

Diabetes is usually irreversible and, although a reasonable life style can be enjoyed, the late complications result in reduced life expectancy.

Macrovascular disease leads to an increased prevalence of coronary artery disease, peripheral vascular disease and stroke.

Favorable scenario:

Diagnosed at > age 60 n A1C levels under 7.0
Duration of disease <15 years
No diabetic complications such as neuropathy, nephropathy, retinopathy, proteinuria
Good kidney functions

Helpful terms:

Hemoglobin A1C: a form of hemoglobin found in the blood which is primarily used to identify the average blood glucose concentration over prolonged periods of time, typically from 4 weeks to 3 months.
Neuropathy: Damage to the small blood vessels that supply all nerves causing numbness and tingling in the extremities, abnormal sensations and muscle weakness.
Nephropathy: A progressive kidney disease caused by damage to the capillaries due to longstanding uncontrolled diabetes.
Retinopathy: Damage to the retina in the eye from microvascular changes which can cause blurry vision and, in extreme cases, blindness.
Proteinuria: The presence of excess levels of protein in the urine due to damage to the kidneys.

Contact Information

Name *

First

Last

Phone *

Email *

Date of Birth *

Height/Weight *

Gender (at birth) *

Male
Female

Tobacco User? *

If "yes", provide information: *

Diagnosis/Treatment Information

Age Of First Diagnosis *

Type of Diabetes *

Insulin dependent diabetes (Type 1)
Non-Insulin dependent diabetes (Type 2)
Impaired fasting glucose
Gestational diabetes

Controlled via: *

Diet & Exercise
Oral Medications
Insulin

List type and dosage: *

List amount of units/day: *

Has the type of medications been stable for the last 6 months? *

If no, please explain: *

Has the dosage of the current medications been stable for the last 6 months? *

If no, please explain: *

Do you check their blood sugar readings on a regular basis? *

If yes, how often and what are the results? *

Date of last hemoglobin A1C level:

What were the results?

Do you have any associated complications from diabetes such as neuropathy, nephropathy, retinopathy or proteinuria? *

If “YES,” please give details: *

Do you have high cholesterol, hypertension, coronary artery disease, cerebrovascular or peripheral vascular disease? *

If “YES,” please explain: *

This is not an application for insurance and in no way guarantees a specific underwriting class or binds any insurance coverage with any insurance carrier. This form is used exclusively to gather specific information on a proposed insured’s medical history and other factors that may impact underwriting and rating classification. Information contained herein is for informational purposes only and is not intended to be a substitute for medical advice.

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