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Microsoft word - gtl declines.doc

CASE 1:
17b. TAKING ATENOLOL PRESCRIBED BY DOCTOR
17d. DEPRESSION, TAKING TOFRANIL PM AND SERAX
20. 1--ATENOLOL 2-- LIPITOR 3-- SERAX 4-- TOFRANIL PM 5-- NIASPAN 6-- VYTORIN ALL PRESCRIBED BY EITHER DOCTOR
CASE 2:
17g. I was diagnosed with type 1 diabetes at age 9. Under control with routine visits to endocrinologist, shots- {basal once a day-
humolog prior to each meal}
20. vytorin-10-40Mg once per day My LdL is normal for non-diabetics-this prescription is a preventive measure. Actos 30 mg once
daily For absorption of insulin at cellular level.
CASE 3:
17b. Recovered from heart attack. No medical procedures performed.
20. Lipitor Aspirin (a couple more.need to look and provide information to you)
CASE 4:
17a. Asthma, and chronic obstructive lung disease currently being treated by physician, and is under control
17b. blood pressure is under control, and treated by doctor
20. medication for blood pressure
CASE 5:
17b. High Blood pressure
17g. Diabetes
20. Insulin Tricor Benzapril Diovan Actos Asacol :Lipitor
CASE 6:
16c. non specific IBD, diet alteration, Dr. Kelly, Missouri Baptist hospital, Ballas rd., st. Louis, MO
16d. Anxieity, Lorazapem as needed
16e. chiropractic care
16f. localized Sarcoma right knee, AKA, chemo
19. Social Security disablity awarded in 1999.
21. Lorazapem, as needed. Lortab, as needed
CASE 7:
12. On diversion probation for apx. 1 more year for E class Felony which was Solicitation of a minor, which will be expunged from my
record at the end of probation. No previous record.
CASE 8:
10. HAD TICKETS MUSIC TO LOUD DID'NT PAY IT.
11. COUPLE YEARS AGO I WAS CONVICTING OF SELLING DRUGS.
CASE 9:
17b. 1. HIGH BLOOD PRESSURE.TAKE ZESTRIL TO CONTROL DAILY, NOW NORMAL BLOOD PRESSURE 2. HIGH
CHOLESTEROL.TAKE LIPITOR DAILY.
17d. TREATED FOR DEPRESSION FOR THE PAST TWO YEARS. I NO LONGER TAKING ANTI-DEPRESSANTS AND I AM DOING MUCH
BETTER.
17e. BROKEN ARM TWICE AS A TEENAGER. NO OTHER PROBLEMS.
18. MY DISABILITY BENEFITS FOR DEPRESSEION END ON JUNE 12, 2005.
20. PLEASE SEE ABOVE.LIPITOR FOR HIGH CHOLESTEROL & ZESTRIL FOR BLOOD PRESSURE. BOTH UNDER CONTROL NOW.
CASE 10:
17d. I am treated for depression. I am also treated for vestibular neuronitis. This is simply a problem that affects my balance. I see
A neurologist every six months however there is no known cure for this problem. I also see A psychiatrist for my depression. Neither
problem is life threatening.
18. I am on S.S.D.I. and I receive long term disability from general motors. I am unable to work by general motors and social
security standards.
20. I take Valume for my balance. I take Zoloft and seroquel for the depression. I also take a drug called Topomax which just helps
me not to have migraine headaches.
CASE 11:
17d. depression treated by Abilify once a day
18. SSI for not being to get a job. He is a full time student now
20. Abilify once a day for depression
CASE 12:
17d. ANXIETY AND DEPRESSION ON MEDS OR THOS TWO ITEMS
18. YES I HAVE BEEN ON DISABILITY FOR 1 YEAR
CASE 13:
17i. Alcohol Abuse - Terminated by Kaiser (underwriter remarks: Sorry, must decline. Can reconsider in 2 years.)
CASE 14:
9. State Farm Life Insurance declined life ins. My blood work showed elevated levels of hepatitis-related enzymes. I consulted a
gastro-entologist who saw no reason for concern --- particularly since I do not drink alcohol. In his view, I may have been infected at
birth. (underwriter remarks: Regret, we cannot consider at this time due to medical history from the Dr. We can reconsider in one
year subject to a medical report.)
CASE 15:
Height 5’10”, 360lbs.
17b. had stints placed in right artery in November of 2004
17g. Underactive Thyroid
20. Levoxyl, Potassium, Allopurinol, Plavix, Zetia
CASE 16:
17g. I am a diabetic, I take insulin to control it.
20. I take Humolog and Lantus for Diabetes
CASE 17:
17b. Heart attached November 4, 2004, stint placed in artery
20. Toprol (1 tab. per day) Zetia (1 tab per day)
CASE 18:
12. On probation for 13 more months. (underwriting remarks: Can reconsider when he gets off of probation in 13 months.)
CASE 19:
17b. I have undergone triple-by-pass three years but since I'm eating a well-diet food, exercise regularly, hence, my medications
have been reduced. I want to live longer for my family's sake.
CASE 20:
17a. Asthma, And the last time I was treated for Asthma was in October 2004
18. Yes, I am receiving disability under Social Security I started receiving that as of Jan 05
20. I take Albuterol it is an inhaler and I take it as needed and the dosage is 17 grams

Source: http://sasid.com/licensing/pdf/GTL%20Declines.pdf

Microsoft word - children and cc draft 26 v2.doc

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