Pre-Qualifying Health Questionnaire

When was your most recent annual physical with your PCP?*

MonthDayYear
Date
When was your last full panel of blood work with your PCP?*

MonthDayYear
Date
Are any of your blood labs outside the range of normal?*

YesNo
If yes, which ones?*
Please list all medications you are currently taking including dosage, reason for taking, and for approximately how long:*
Have you been prescribed medications that you chose not to take or stopped taking without your MD discontinuing the recommendation or order?*

YesNo

Do you currently have HIV/AIDS?*

YesNo
Do you have ALS, Cirrhosis, Cystic Fibrosis, Huntington’s Chorea, Kidney Disease, Memory Issues, Muscular Dystrophy, Multiple Sclerosis, Parkinson’s, Schizophrenia, Systemic Lupus?*

YesNo
Do you currently use: Cane, walker, wheelchair, electric scooter, stairlift, hospital bed, nebulizer, or oxygen?*

YesNo
Do you currently receive: Benefits under Disability Income, Medicaid, Social Security Disability, or Workers Compensation?*

YesNo

Other
Have you looked at long term care insurance previously?*

YesNo
Are you presently looking at long term care insurance with another source?*

YesNo
Have you been declined for long term care insurance?*

YesNo
Who referred you to us?*
NOTE: Please make sure to click SUBMIT above to ensure your information has been sent. You will receive an email confirmation a few minutes later which confirms your entry was submitted.
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This Health Form is HIPAA compliant to protect your personal information.