Long-Term Care Insurance Health Questionnaire

1
Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Date of Birth* This field is required.
Date
Year
Month
Day
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Height* This field is required.
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
5
Weight* This field is required.
90
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375
6
Have you lost more than 10 lbs. in the past 12 months?* This field is required.
YESNO
7
How much weight have you lost in the past 12 months?Think Specific 12 month period. If you've been losing weight for 15 months, only put in what you've lost in the past 12 months. The lower the number the better you are for underwriting.
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8
Have you ever used tobacco products?* This field is required.
YESNO
9
Are you a current user?* This field is required.
YESNO
10
Tobacco Use Details
Type of Tobacco
Frequency of Use
Most Recent Use Date
11
When did you last use a tobacco product?
Date
Year
Month
Day
12
Have you ever used marijuana products?* This field is required.
YESNO
13
Marijuana Use Details
Frequency of Use
Most Recent Use Date
14
Have you ever been declined, rated, or denied reinstatement for an LTC policy?
YESNO
15
Details of decline, rating, or denial of reinstatement:
Name of Company
Date
Reason
16
Do you currently use any of the following?
Wheelchair
Nebulizer
Walker
Electric Scooter
Quad Cane
Oxygen
Hospital Bed
Respirator
Kidney Dialysis
Crutches
Stair Lift
17
Please provide details for why you utilize the previous for assistance.
Huge
Large
Normal
Small
Ok
Ok
18
Have you been confined to, or been advised to have, or used any of the following:
Residential Care
Assisted Living or Adult Day Care Facility ServicesNEXT
Nursing Home or Home Health Care Services
Long-Term Care Facility
Physical Therapy
Occupational Therapy
Speech Therapy
Hospital
19
Please provide details for why you utilize(d) the previous for assistance.
Huge
Large
Normal
Small
Ok
Ok
20
Do you require assistance or supervision of another person or device of any kind for any of the following?
Bathing
Toileting
Dressing
Eating
Walking
Medication mangement
Getting in and out of a chair or bed
Control of bowel or bladder
21
Are you currently eligible for benefits under, or covered by or received Medicaid, Disability Income, Worker's Compensation, Social Security Disability, or any Federal or State Disability Plan?
YESNO
22
Please provide details
Huge
Large
Normal
Small
Ok
Ok
23
Do you require assistance with shopping, using transportation, or housekeeping/cooking?
YESNO
24
Are you currently taking any medications?* This field is required.
YESNO
25
Please provide the name, dosage, and frequency of each medication* This field is required.
26
Have you received inpatient or outpatient treatment at a hospital, surgical center, or rehabilitation facility in the past five years?
YESNO
27
Please provide reason and date(s).
Huge
Large
Normal
Small
Ok
Ok
28
Are you scheduled for, or have you been advised by a physician or health care provider, to have additional testing, surgery or consultation(s) to evaluate health?
YESNO
29
Please provide as many details as possible.
Huge
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Ok
Ok
30
Health Details* This field is required.
When was your last physical and full lab work completed?
When was your last doctor visit for any reasons?
Why did you visit the most recent doctor, and what was the outcome?
31
Has your mother, father, sibling, or grandparent been diagnosed with Alzheimer's or Dementia?
YESNO
32
Please state which relation was diagnosed and about the age of the onset.
Huge
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Normal
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Ok
Ok
33
To the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations, or diagnosis from a physician or health care provider for any of the following conditions?
Alzheimer's Disease
Brain Disorder
Dementia
Mental or Cognitive Disorder
Epilepsy / Seizures
Neurological Disease / Disorder
Tremor
Amyotrophic Lateral Sclerosis (ALS)
Cerebrovascular Disease
Depression or Mental Illness
Huntington's Chorea
Memory Loss or Forgetfulness
Mental Retardation
Schizophrenia / Psychosis
Neuropathy
Bipoloar Disorder
Cerebrovascular Accident / Stroke
Dizziness / Vertigo
Ministroke or TIA
Senility
Parkinson's Disease
Other
34
Please provide details for the previous marked condition(s).date of onset, medication prescribed, current condition, etc...
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Ok
Ok
35
To the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?
Abnormal Blood Pressure
Atrial Fibriliation
Coronary Artery Disease
Anemia or Blood Disease
Cardiomyopathy
Defibrillator
Aneurysm
Cartoid Artery Disease
Heart Attack
Angioplasty / Heart or Bypass Surgery
Congestive Heart Failure
Heart Valve Disorder
36
Please provide details for the previous marked condition(s).date of onset, medication prescribed, current condition, etc...
Huge
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Normal
Small
Ok
Ok
37
To the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?
Bowel or Bladder Disease/Disorder
Colitis
Chrohn's Disease
Diabetes
Endocrine or Pituitary Disorder
Gastrointestinal Disorder
Neurogenic Bladder
Kidney Failure or Dialysis
Kidney or Liver Disease / Disorder
Thyroid Disease
38
Please provide details for the previous marked condition(s).date of onset, medication prescribed, current condition, etc...
Huge
Large
Normal
Small
Ok
Ok
39
To the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?
Amputation
Disabling Back or Spine Condition
Musculoskeletal Disorder
Arthritis
Falls or Injuries due to Falls or Imbalance
Osteoporosis
Back, Bone, Joint Disorder / Broken Bones
Joint Replacement Surgery
Paralysis
Difficulty Walking
Muscular Dystrophy
Post-Polio Syndrome
Spinal Cord Injury
40
Please provide details for the previous marked condition(s).date of onset, medication prescribed, current condition, etc...
Huge
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Normal
Small
Ok
Ok
41
To the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?
Cancer
Leukemia
Lymphoma
Multiple Myeloma
Hodgkin's Disease
42
Please provide details for the previous marked condition(s).date of onset, medication prescribed, current condition, etc...
Huge
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Normal
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Ok
Ok
43
To the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?
AIDS / ARC
Immune System Disease / Disorder
Polymyositis
Cirrhosis
Lupus
Rheumatoid Arthritis
Fibromyalgia
Multiple Sclerosis (MS)
Sarcoidosis
Hepatitis
Myasthenia Gravis
Scleroderma / CREST Syndrome
44
Please provide details for the previous marked condition(s).date of onset, medication prescribed, current condition, etc...
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Normal
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Ok
Ok
45
To the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?
Alcohol or Drug Abuse
Organ Transplant
Asthma / COPD / Emphysema
Skin Ulcers
Cystic Fibrosis
Unexplained / Unplanned Weight Loss/Gain
Ear or Eye Disorder
Weakness or Fatigue
46
Please provide details for the previous marked condition(s).date of onset, medication prescribed, current condition, etc...
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Ok
Ok
Should be Empty: