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Clear Sinclair FormSUPPLEMENT TO INDIVIDUAL LIFE INSURANCE APPLICATION Eligibility for Chronic Illness (Print and Use Black Ink) PROPOSED INSURED 1. Last Name First Name M Social Security or Tax ID
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Begin the form by providing personal information such as name, date of birth, and contact details.
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Move on to the section where you can describe the symptoms experienced. Be as detailed as possible, including any changes in sensation, muscle weakness, or bladder and bowel problems.
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If known, mention the date of the initial symptom onset and any subsequent flare-ups or relapses.
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Indicate if any medical tests have been conducted to confirm the diagnosis of transverse myelitis, such as MRI scans or lumbar punctures.
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It is important for individuals experiencing symptoms or suspecting that they may have transverse myelitis to seek medical attention for proper evaluation, diagnosis, and treatment.
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Transverse myelitis is a neurological disorder caused by inflammation across both sides of one level, or segment, of the spinal cord.
Patients who have been diagnosed with transverse myelitis may be required to report their condition to medical professionals and authorities.
Transverse myelitis can be filled out by providing detailed medical history, symptoms, and diagnostic test results to healthcare providers.
The purpose of transverse myelitis is to monitor and manage the neurological symptoms and complications associated with the condition.
Information to be reported on transverse myelitis may include medical history, symptoms, diagnostic tests, treatment plans, and follow-up care.
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