. . National Life Insurance Company” National Life Life Insurance Company of the Southwest” Group*® Blood Pressure Questionnaire Name (please pring: Date of Birth Policy #: Date Completed: Date of diagnosis: What medication(s) are you currently taking and dosage(s)? Has there been any change in your medication in the past 12 months? (if Yes, please provide deals) Have you ever required hospitalization or emergency room treatment for this condition? (if Yes, please provide deals) Do you have any blood pressure related health problems such as: kidney disease, enlarged heart or history ofa stroke, other? (if Yes, please provide deals) Do you self monitor your blood pressure? yes, please provide most recent reading Date of last blood pressure checkup by your doctor and reading: Ces [No Ces [No CYes [No Dyes CINo ‘Area of Specially Physician's Name Address/Telephone Number | Date Last Seen/Frequency | (ie. famiy physician, carilogst. ther '3625(0112) __Naional Life Group i wade rama of Natonal Life Insurance Company, Montpalia, VT, Life surance Company of the (cat. No. 50788 Southwest (LSI), Addison, TX and thor aflats. Each company of National Life Groups solely sponsible for ts own financial condition and contractual obligalons. LSW is not an authorized insurer in New York and does not conduct insurance busines in New York, Centralized Maling Address: One National fe Drive, Montpelier, VT 05604 | www.NatonalLifeGreup.com