Harbor Life Questionnaire

1
Insured Name
First Name
Last Name
2
Insured Phone Number
Please enter a valid phone number.
3
Insured Email
example@example.com
4
Policy Type
Universal
Term
Convertible Term
Whole
Variable
Group Term
Group Universal
5
What is the insured's date of birth?* This field is required.
6
What is the insured's gender?
Male
Female
7
Carrier* This field is required.
Select Carrier
Select Carrier
5Star Life Insurance Company
AARP
Acacia Life
Accordia Life Insurance
AEGON
Aetna
Aflac
AICPA
AIG Direct
Allianz Insurance
Allstate
American Amicable
American Automobile Association (AAA)
American Equity
American Family Insurance
American Fidelity Life Insurance Company
American General Life Insurance Company
American Income Life
American International Group
American Memorial
American National Insurance Company
American United Life (AUL)
Americo Life
Ameriprise Financial
Ameritas
Assurity Life Insurance Company
AXA Equitable Life Insurance Company
Bankers Life and Casualty Company
Banner Life
Berkshire Life Insurance Company
Boston Mutual
Brighthouse Financial
Christian Fidelity
Cincinnati Insurance
CMFG Life Insurance Company
CNO Financial Group
Colonial Life
Colonial Penn
Combined Insurance
Columbian Mutual Life
Columbus Life Insurance Company
Connecticut Mutual Life Insurance
CUNA Mutual
Delaware Life
EMC National Life Company
Equitrust Life Insurance Company
Erie Insurance
Family Life Insurance
Farm Bureau Insurance
FEGLI
Fidelity Life Association
Farmers Insurance Group
Fidelity Security Life Insurance Company
First United American
Foresters
Forethought Life Insurance
GEICO
Genworth Financial
Gerber Life Insurance Company
Globe Life
Great American Insurance
Great-West Financial
Great Western Insurance Company
Guarantee Trust Life
Guardian Life Insurance Company
Horace Mann
The Hartford
Illinois Mutual
ING Life Insurance
Investor Heritage
Jackson National
John Hancock Insurance
Kansas City Life Insurance Company
Kemper Corporation
Knights of Columbus
LaFayette Life
Legal & General America
Liberty Bankers
Liberty Mutual
Life Insurance Company of Alabama
Lincoln Financial Group
Lincoln Heritage Life Insurance
Madison National
Manhattan Life Insurance Company
MassMutual
MetLife
Midland National
Minnesota Life
Motorists Life Insurance
Mutual of Omaha
Mutual Trust Life Insurance
National Guardian Life
National Income Life
National Life Group
Nationwide Life Insurance Company
Navy Mutual
New Era Life
New York Life Insurance Company
North American Company for Life and Health
North American Insurance Company
Northwestern Mutual Life Insurance Company
Ohio National
Oxford Life Insurance
Pacific Life
Pan-American Life
Penn Mutual
Petersen International Underwriters
Phoenix Life
Physicians Mutual
PolicyGenius
Primerica
Principal Financial Group
Progressive Life
Protective Life Insurance Company
Prudential Financial
Riversource Life
Sagicor Life Insurance
Royal Neighbors of America
Savings Bank Life Insurance (SBLI)
Securian Life Insurance Company
Security Life of Denver Insurance Company
Security Mutual Life Insurance Company of New York
Security National Life Insurance Company
SelectQuote
Senior Life Insurance Company
Sentinel Security Life Insurance Company
Servicemembers Group Life Insurance
Settlers Life
Shelter Insurance Companies
Southern Farm Bureau Life Insurance Company
Sun Life Financial
Standard Insurance Company
Standard Life and Casaulty
Starmount Life Insurance Company
State Farm Life Insurance
Symetra Life Insurance Company
Thrivent Financial
TIAA-CREF
Transamerica Corporation Insurance Company
United American Insurance Company
United Home Life
United of Omaha
Unum Group
USAA Life Insurance
Vantis Life Insurance
Veterans Group Life Insurance
VOYA Life Insurance
Washington National Insurance Company
West Coast Life
Western and Southern Life Assurance Company
William Penn Life Insurance
WoodmenLife
Other-Carrier Not Listed
8
Issue Date* This field is required.
9
Policy ID* This field is required.
10
Face Amount* This field is required.
11
State* This field is required.
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Issue Class
13
Agent Company
14
Agent Name* This field is required.
First Name
Last Name
15
Agent Email* This field is required.
example@example.com
16
Agent Phone Number* This field is required.
Please enter a valid phone number.
17
Insured's Health Status
Select an Option
Select an Option
Healthy or average
Minor (ex. diabetes)
Terminal (ex. cancer)
18
Do you smoke every day?* This field is required.
Yes
No
19
How many drinks do you have per day?
0
1
2
3
4
5
6
7
8 or more
20
Drinks Number
21
Drinks Debits
22
Has there been treatment for Alcohol Abuse in the last 5 years?* This field is required.
Yes
No
23
Alcohol Abuse Debits
24
Height* This field is required.Please enter your height in ft and inches:
feet
inches
25
Height in Meters
26
Weight* This field is required.Please enter your weight in lbs
27
Weight in Kilograms
28
BMI
29
BMIDebits
30
Please Select Any Major Illnesses Listed Below:
Cardiovascular (Heart)
Cerebrovascular (Brain)
Peripheral Vascular Disease and Aneurysm
Pulmonary (Lungs)
Diabetes
Kidney Disease
Liver Disease
Hematology (Blood)
Cancer (Treatment w/in 5yrs)
Neurological (Nervous System)
Frailty & Functional Impairments
31
What is your average blood pressure?If you don't know, or you don't have high blood pressure, use 120/80
Systolic
Diastolic
32
Blood Pressure Debit
33
Do you have Coronary Artery Disease?Also called atherosclerosis, this is the buildup of plaque & deposits in your arteries
YESNO
34
How many surgical interventions have you had within the last 10 years (angioplasty, stent, bypass, etc.)?This includes all coronary procedures & surgeries, but NOT diagnostic tests like EKGs, or stress tests.
35
Surgical Intervention Debits
36
Do you have Cardiomyopathy/Congestive Heart Failure? What level?
None
Mild, class 1-2 (some dyspnea or shortness of breath, ejection fraction 41-54%)
Moderate, class 3 (dyspnea or short of breath with normal activity, ejection fraction 35-40%)
Severe, class 4 (dyspnea or shortness of breath at rest, limited physical capabilities, ejection fraction <35%)
37
Cardiomyopathy Debits
38
Do you have Valve Disease (aortic, mitral, tricuspid valve insufficiency or stenosis); if so, at what level?Do you have a problem with any of your heart valves?
None
Mild
Moderate
Severe
Valve repair/replacement within the last 5 years?
39
Valve Disease Debits
40
Do you have Pulmonary Hypertension; if so, at what level?Pulmonary hypertension is a type of high blood pressure that affects the arteries in your lungs and the right side of your heart.
None
Mild
Moderate
Severe
41
Pulmonary Hypertension Debits
42
Do you have Chronic Atrial Fibrillation; if so, is it controlled?Atrial fibrillation (or Afib) is an irregular heartbeat.
None
Controlled with Medication
Untreated
43
Chronic Atrial Fibrillation Debit
44
Have you had a Stroke/TIA in the past 5 years?TIA (transient ischemic attack) is sometimes called a mini-stroke.
No
Yes
Yes with residual deficits
45
Stroke Debits
46
Do you have Carotid artery disease; if so at what level?Carotid disease is the blocking or narrowing of your carotid artery
None
Mild (<50% stenosis)
Moderate (50-69% stenosis)
Severe (>75% stenosis)
47
Carotid Disease Debit
48
Do you have Peripheral Vascular Disease (PVD) of lower extremities?PVD is a blood circulation disorder that pain and fatigue in your legs.
YESNO
49
Peripheral_Vasc_Disease_Debit_MortCalc
50
Have you had lower extremity stent or vein surgery within the last 5 years or chronic wound/ulceration repair?
YESNO
51
Lower_Extremity_Stent_Debit_MortCalc
52
Have you had an Aneurysm; if so choose from the following?
None
>5 cm aortic aneurysm (unrepaired)
>6 cm aortic aneurysm (unrepaired)
recent aneurysm repaired within the last 5 years
Not sure
53
Aortic_Aneurysm_Debit_MortCalc
54
Do you have COPD/Emphysema; if so, at what level?
None
Mild (minimal symptoms, dyspnea only with heavy exertion)
Moderate (chronic symptoms, dyspnea with normal exertion)
Severe (dyspnea with any exertion, use of oxygen)
55
COPD_Emphysema_Debit_MortCalc
56
Do you have Asthma?Steroidal inhalers include Flovent, Pulmicort, Advair, Dulera
No
Yes
Yes with use of Steroidal Inhaler
57
Asthma_Debit_MortCalc
58
Do you have Sleep Apnea; if so, at what level?
None
Mild
Moderate
Severe
59
Do you use a CPAP or BiPAP?
YESNO
60
Sleep_Apnea_Debit_MortCalc
61
What was your date of diagnosis for Diabetes?
None
< 15 years ago
> 15 years ago
62
Diabetes_Diagnosis_Date_Debit_MortCalc
63
What is your Average A1c level?
< 8.0
8.0 - 10.0
> 10.0
Not sure
64
Average_A1c_Debit_MortCalc
65
Do you have any of the following: Diabetic neuropathy, foot ulcerations, circulatory disorders?Diabetic neuropathy is nerve damage/pain due caused by diabetes. This question also includes ulcers or sores on your feet/legs due to diabetes.
YESNO
66
Neuropathy_ulcers_circ_debit_MortCalc
67
Do you have any of the following: Diabetic nephropathy, diabetic kidney disease?Diabetic nephropathy is kidney disease caused by diabetes.
YESNO
68
Diabetic_Nephropathy_Debit_MortCalc
69
Do you have diabetic retinopathy?Diabetic retinopathy causes eye and vision problems due to diabetes.
YESNO
70
Diabetic_Retinopathy_Debit_MortCalc
71
Have you been diagnosed with chronic kidney disease or renal insufficiency; if so, at what level?
None
Stage 1-2 (GFR 60–90+)
Stage 3 (GFR 30-59)
Stage 4 (GFR 15-29)
Stage 5 (GFR <15)
72
Chronic_Kidney_Disease_Debit_MortCalc
73
Are you currently receiving dialysis treatments?
YESNO
74
Dialysis_Debit_MortCalc
75
Have you received a kidney transplant?
YESNO
76
Kidney_Transplant_Debit_MortCalc
77
Have you been diagnosed with fatty liver disease or non-alcoholic steatohepatitis within the past 5 years?
YESNO
78
FattyLiver_Steatohepatitis_Debit_MortCal
79
Do you have Liver cirrhosis; if so, at what level?
None
Early Stage
Advanced Stage
Liver Transplant
80
Liver_Cirrhosis_Debit_MortCalc
81
Do you currently have anemia; if so at what level?
None
Mild
Moderate
Severe
82
Anemia_Debit_MortCalc
83
Have you been diagnosed with a platelet disorder including thrombocytopenia or thrombocytosis?Thrombocytopenia is low levels of blood platelets. Thrombocytosis is too many platelets in your blood which increases risk of blood clots.
YESNO
84
Platelet_Disorder_Debit_MortCalc
85
Have you been diagnosed with polycythemia vera that requires treatment with phlebotomies or prescription medications? Polycythemia vera is a type of blood cancer that causes too many platelets, and increasing risk of blood clots.
YESNO
86
Polycythemia_w_Treatment_Debit_MortCalc
87
Have you been diagnosed with monoclonal gammopathy (MGUS)? MGUS causes elevated M protein in your blood.
YESNO
88
Monoclonal_gammopathyMGUS_Debit_MortCalc
89
Have you been diagnosed with myeloproliferative disorder or myelodysplastic syndrome (MDS) within the past 5 years? Both of these disorders cause disruptions in the production of blood cells or cause them to grow abnormally.
YESNO
90
Myeloproliferative_MDS_Debit_MortCalc
91
Select the type of cancer(s) you have:
Acute Myeloid Leukemia (AML)
Bladder/Urethral
Bone
Brain
Breast
Chronic Lymphocytic/Myeloid Leukemia
Colon/Rectal
Endometrial/Ovarian/Cervix
Esophageal
Hodgkin's Lymphoma
Kidney
Laryngeal
Liver
Lung/Mesothelioma
Multiple Myeloma
Non-Hodgkin's Lymphoma
Ocular/Eye
Oral (lip, tongue, etc.)
Other
Pancreatic
Prostate
Skin
Soft Tissue/Sarcoma
Stomach/Digestive
Testicular
Thyroid
92
Please select the appropriate stage of Acute Myeloid Leukemia (AML):* This field is required.This is sometimes called acute non-lymphocytic leukemia. It affects the blood & bone marrow. If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
93
Acute_Myeloid_Leukemia_Debit_MortCalc
94
Please select the appropriate stage of Bladder/Urethral Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
95
Bladder_Urethral_Debit_MortCalc
96
Please select the appropriate stage of Bone Cancer:* This field is required.Includes all types of bone cancers, also called sarcomas. If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
97
Bone_Debit_MortCalc
98
Please select the appropriate stage of Brain Cancer:* This field is required.Includes all types of brain cancers such as astrocytomas, meningioma, and gliomas. If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
99
Brain_Debit_MortCalc
100
Please select the appropriate stage of Breast Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
101
Breast_Debit_MortCalc
102
Please select the appropriate stage of Chronic Lymphocytic/Myeloid Leukemia:* This field is required.CLL & CML are types of blood cancer. If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
103
Lymphocytic_MyeloidLeuk_Debit_MortCalc
104
Please select the appropriate stage of Colon/Rectal Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
105
Colon_Rectal_Debit_MortCalc
106
Please select the appropriate stage of Endometrial/Ovarian/Cervix Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
107
CervicalOvarianEndometrial_Debit_MortCal
108
Please select the appropriate stage of Esophageal Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
109
Esphogeal_Debit_MortCalc
110
Please select the appropriate stage of Hodgkin's Lymphoma:* This field is required.Sometimes called Hodgkin's disease. If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
111
HodgkinsLymphoma_MortCalc
112
Please select the appropriate stage of Kidney Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
113
Kidney_Debit_MortCalc
114
Please select the appropriate stage of Laryngeal Cancer:* This field is required.Cancer of the larynx (voicebox). If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
115
Laryngeal_Debit_MortCalc
116
Please select the appropriate stage of Liver Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
117
Liver_Debit_MortCalc
118
Please select the appropriate stage of Lung Cancer/Lung/Mesothelioma:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
119
Lung_Mesothelioma_Debit_MortCalc
120
Please select the appropriate stage of Melanoma:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
121
Melanoma_Debit_MortCalc
122
Please select the appropriate stage of Basal Cell Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
123
Please select the appropriate stage of Squamous Cell Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
124
Please select the appropriate stage of Multiple Myeloma:* This field is required.Cancer of the blood plasma. If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
125
Multiple_Myeloma_Debit_MortCalc
126
Please select the appropriate stage of Non-Hodgkin's Lymphoma:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
127
NonHodgkins_Lymphoma_Debit_MortCalc
128
Please select the appropriate stage of Ocular/Eye Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
129
Ocular_Eye_Debit_MortCalc
130
Please select the appropriate stage of Oral Cancer (lip, tongue, etc):* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
131
Oral_Debit_MortCalc
132
Please select the appropriate stage of Other Cancer:* This field is required.Any cancers not otherwise listed. If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
133
Other_Cancer_Debit_MortCalc
134
Please select the appropriate stage of Pancreatic Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
135
Pancreatic_Debit_MortCalc
136
Please select the appropriate stage of Prostate Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
137
Prostate_Debit_MortCalc
138
Please select the appropriate stage of Soft Tissue/Sarcoma:* This field is required.May be called liposarcoma or malignant schwannoma. If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
139
SoftTissue_Sarcoma_Debit_MortCalc
140
Please select the appropriate stage of Stomach/Digestive Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
141
Stomach_Digestive_Debit_MortCalc
142
Please select the appropriate stage of Testicular Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
143
Testicular_Debit_MortCalc
144
Please select the appropriate stage of Thyroid Cancer:* This field is required.If your cancer has spread to other organs, please select stage 4.
Remission
Stage 1
Stage 2
Stage 3
Stage 4
Stage Unknown
N/A
145
Thyroid_Debit_MortCalc
146
Mild cognitive impairment (MCI) or memory loss that is treated with medications* This field is required.This question is asking about major memory loss requiring medication.
YESNO
147
Cognitive_Impairment_Debit_MortCalc
148
Alzheimer’s/Dementia* This field is required.
None
Mild
Moderate
Severe
149
Alzheimers_Dementia_Debit_MortCalc
150
Parkinson’s* This field is required.
None
Mild
Moderate
Severe
151
Parkinsons_Debit_MortCalc
152
Amyotrophic Lateral Sclerosis (ALS)/Lou Gehrig’s Disease* This field is required.
YESNO
153
ALS_Lou_Gehrigs_Debit_MortCalc
154
Multiple Sclerosis (MS)* This field is required.
None
Mild
Moderate
Severe
155
Multiple_Sclerosis_Debit_MortCalc
156
Select all that apply
Gait/Balance difficulties
History of falls
Use of assistive devices for mobility (cane, walker, wheelchair, etc.)
Poor coordination
Memory loss
Moderate-Severe depression
Vision problems
Significant arthritis or orthopedic issues
Chronic pain
Assistance need for activities of daily living (ADLs)
Current residence in assisted living facility or nursing home; Use of in-home caregiver
157
Do you have Gait/Balance difficulties?Do you have ongoing issues with walking/balance?
YESNO
158
Do you have a history of falls?Have you fallen more than once in the last 6 months?
YESNO
159
Do you use assistive devices for mobility (cane, walker, wheelchair, etc.)Do you use an assistive device occasionally or all the time?
YESNO
160
Do you have poor coordination?Do you have poor fine motor skills or difficulty with hand-eye coordination the impacts your daily activities?
YESNO
161
Do you suffer from memory loss?Do you have ongoing problems with memory that are severe or worsening that impacts your daily activities?
YESNO
162
Do you have moderate-severe depressionDo you have depression that requires medication or that interferes with your daily activities?
YESNO
163
Do you have vision problems?Do you have vision problems that impact your daily activities?
YESNO
164
Do you have significant arthritis or orthopedic issues?Do you have arthritis that impairs your ability to complete tasks on your own?
YESNO
165
Do you have chronic pain?Do you have chronic pain that impacts your daily activities?
YESNO
166
Do you require assistance for activities of daily living (ADLs)Do you need help completing daily tasks such as getting around, bathing, eating, dressing, or using the bathroom?
YESNO
167
Is your current residence in an assisted living facility or nursing home, or do you use an in-home caregiver?
YESNO
168
FrailtyCalculation
169
FrailtyDebits
170
MortalityFactor* This field is required.
Should be Empty: