If your client has a history of Parkinson's Disease, please answer the following :
1. Date of first diagnosis ?
2. Current functional stage of your client ?
Stage I unilateral involvement
Stage II bilateral involvement but normal stance
Stage III bilateral involvement with mild postural imbalance
but able to lead an independent life
Stage IV bilateral involvement with postural instability,
requires substantial help
Stage V severe disease; restricted to bed or wheelchair
3. Has there been any evidence of progression ? Yes No If yes, give details:
4. Is your client on any medication ? Yes No If yes, give details:
5. Have any of the following problems ocurred ?
6. Has your client smoked cigarettes in the last 12 months ? Yes No
7. Does your client have any major health problems ? Yes No (example: cancer, etc.)
If yes, give details:
The underwriter will respond back to you on this case within 48 hours,