Language
English (US)
Health and Financial Information Form
The information in this form is confidential. Your health assessment will help me to help you with what LTC benefits to recommend. The information is encrypted, and this digital form will be sent to Raymond Lavine.
Name
*
First Name
Last Name
Email
*
example@example.com
State of Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Fill Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
*
Date of Birth
*
-
Month
-
Day
Year
Date
How did you find us?
Please Select
Facebook
Google
Friend/Family
Wealth Advisor
Other
What are your concerns that you are considering LTC Benefits?
*
Back
Next
Save
Spouse or Partner Information
Optional
Spouse/Partner name
First Name
Last Name
Email
example@example.com
State of Residence
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Phone number
Your Personal Details
Gender
Please Select
Male
Female
Choose not to identify
Weight and Height
*
Tobacco Use
Yes
No
Back
Next
Save
Back
Next
Save
Spouse/Partner Information
Optional
Spouse/Partner Gender
*
Please Select
Male
Female
Choose not to identify
Spouse/Partner Weight and Height
*
Tobacco Use
Yes
No
Medical Details
Complete information for you and your spouse/partner (if applicable). Identify whether this information is for yourself or spouse/partner.
Primary care physician
*
Enter their full name here
Contact Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse/Partner primary care physician
*
Enter their full name here
Contact Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Specialist Information
*
Name
Last Visit?
Specialty Type?
Phone Number
Email
Address
Who
Specialist 1
Me
Spouse/Partner
Specialist 2
Me
Spouse/Partner
Specialist 3
Me
Spouse/Partner
Specialist 4
Me
Spouse/Partner
Specialist 5
Me
Spouse/Partner
Medical Test History
*
Name
Type
Who?
Test Name
Me
Spouse/Partner
Test Name
Me
Spouse/Partner
Test Name
Me
Spouse/Partner
Test Name
Me
Spouse/Partner
When was your last prostate exam
-
Month
-
Day
Year
Date
When was your Spouse/Partner's last prostate exam
-
Month
-
Day
Year
Date
Medication
*
Name
Type
Who?
Medication Name
Me
Spouse/Partner
Medication
Name
Me
Spouse/Partner
Medication
Name
Me
Spouse/Partner
Medication
Name
Me
Spouse/Partner
Medication Name
Me
Spouse/Partner
Medication Name
Me
Spouse/Partner
Medication Not Taken
Name
Type
Who?
Medication Name
Me
Spouse/Partner
Medication
Name
Me
Spouse/Partner
Medication
Name
Me
Spouse/Partner
Medication
Name
Me
Spouse/Partner
*
Hospitalization, Outpatient Surgery, & ER Visits
Have you been a patient for the following in the past 5 years?
Hospitalization
Outpatient
Emergency room
Details about your visit(s)?
Add your details here
Has your Spouse/Partner been a patient for the following in the past 5 years?
Hospitalization
Outpatient
Emergency room
Details about your Spouse/Partner visit(s)?
Add your Spouse/Partner details here
Medication History
If you have ever received any advice, treatment, consultation, or diagnosis from a physician or health care provider for any of the listed conditions, please indicate the year in which the event occurred. For any condition specified here, please provide additional details in the space provided.
My Known Health Conditions
Yes
Year Known
Other Details?
Alcohol Consumption
Amputation
Anemia
Aneurysm
Anxiety
Arthritis
Back Pain
Balance Disorder
Blood Clotting
Blood Disorder
Bone or Joint Disorder
Bowel or Bladder Disorder
Broken Bone
Cancer
Carotid
Chronic Pain
Circulatory Disorder
Coronary Artery Disease
Depression
Diabetes
Difficulty Walking
Dizziness or Vertigo
Epilepsy
Fainting
Falls
Fatigue
Fibromyalgia
Head Injury
Spouse/Partner Known Health Conditions
Yes
Year Known
Other Details?
Alcohol Consumption
Amputation
Anemia
Aneurysm
Anxiety
Arthritis
Back Pain
Balance Disorder
Blood Clotting
Blood Disorder
Bone or Joint Disorder
Bowel or Bladder Disorder
Broken Bone
Cancer
Carotid
Chronic Pain
Circulatory Disorder
Coronary Artery Disease
Depression
Diabetes
Difficulty Walking
Dizziness or Vertigo
Epilepsy
Fainting
Falls
Fatigue
Fibromyalgia
Head Injury
Skeletal Health
Choose yes or not option for each option.
Joint replacement conducted or recommended in the last 5 years?
Please Select
Yes
No
Yes/No
Have you had cortisone or other joint injections in the last 5 years?
Please Select
Yes
No
Yes/No
Do you have any joint deformities?
Please Select
Yes
No
Yes/No
Do you use any mobility aids such as a walker or crutches?
Please Select
Yes
No
Yes/No
Spouse/Partner Skeletal Health
Optional - Choose yes or not option for each option.
Joint replacement conducted or recommended in the last 5 years?
Please Select
Yes
No
Yes/No
Have you had cortisone or other joint injections in the last 5 years?
Please Select
Yes
No
Yes/No
Do you have any joint deformities?
Please Select
Yes
No
Yes/No
Do you use any mobility aids such as a walker or crutches?
Please Select
Yes
No
Yes/No
HIV/AID Questions
Choose yes or not option for each option. Please provide more details if you are positive.
Have you been diagnosed as having AIDS?
Please Select
Yes
No
Yes/No
Have you been diagnosed as having AIDS Related Complex (ARC)?
Please Select
Yes
No
Yes/No
Have you been diagnosed as having HIV (symptomatic or asymptomatic)?
Please Select
Yes
No
Yes/No
Please provide additional details about your HIV/AIDs diagnosis
Enter details here
Spouse/Partner HIV/AID Questions
Optional. Choose yes or not option for each option. Please provide more details if you are positive.
Has your Spouse/Partner been diagnosed as having AIDS?
Please Select
Yes
No
Yes/No
Has your Spouse/Partner been diagnosed as having AIDS Related Complex (ARC)?
Please Select
Yes
No
Yes/No
Has your Spouse/Partner been diagnosed as having HIV (symptomatic or asymptomatic)?
Please Select
Yes
No
Yes/No
Please provide additional details about your Spouse/Partner HIV/AIDs diagnosis
Enter details here
Back
Next
Save
Applicant Mobility and Disability Questions
Do you currently qualify for payment or are you receiving payment benefits under Medicaid (not Medicare), disability income plan, workers’ compensation, Social Security disability, or any federal or state disability plan?
Please Select
Yes
No
Do you require the assistance or supervision of another person or a device of any kind for bathing, toileting, dressing, eating, medication management, getting in and out of a chair or bed, or inability to control your bowel or bladder?
Please Select
Yes
No
Within the past 6 months have you used or been advised to use residential care, assisted living or adult day care facility services, nursing home, or home health care services?
Please Select
Yes
No
Have you ever been on disability?
Please Select
Yes
No
Have you ever been declined for long term care insurance?
Please Select
Yes
No
If you selected Yes for any of the Mobility questions, please elaborate.
Spouse/Partner Applicant Mobility and Disability Questions
Does your Spouse/Partner require the assistance or supervision of another person or a device of any kind for bathing, toileting, dressing, eating, medication management, getting in and out of a chair or bed, or inability to control your bowel or bladder?
Please Select
Yes
No
Does your Spouse/Partner currently qualify for payment or are you receiving payment benefits under Medicaid (not Medicare), disability income plan, workers’ compensation, Social Security disability, or any federal or state disability plan?
Please Select
Yes
No
Within the past 6 months has Spouse/Partner used or been advised to use residential care, assisted living or adult day care facility services, nursing home, or home health care services?
Please Select
Yes
No
Has your Spouse/Partner ever been on disability?
Please Select
Yes
No
Has your Spouse/Partner ever been declined for long term care insurance?
Please Select
Yes
No
If your Spouse/Partner was Yes for any of the Mobility questions, please elaborate.
Back
Next
Save
Questions About Diabetes
Have you been diagnosed with diabetes?
Please Select
Yes
No
Age at diagnosis
Do you have a history of stroke?
Please Select
Yes
No
Do you have a history of transient ischemic attack?
Please Select
Yes
No
Do you have a history of congestive heart failure?
Please Select
Yes
No
Your typical fasting blood sugar rate
mg/dL
Your most recent A1C hemoglobin test
Percentage
Do you have a history of neuropathy, tingling, numbness, or pain in arms or legs?
Please Select
Yes
No
Have you experienced skin ulcers?
Please Select
Yes
No
Have you experienced kidney, vascular, or circulation problems?
Please Select
Yes
No
Have you experienced vision problems?
Please Select
Yes
No
Questions About Partner/Spouse Diabetes
Has your Spouse/Partner been diagnosed with diabetes?
Please Select
Yes
No
Age at diagnosis (Spouse/Partner)
Do you have a history of stroke?
Please Select
Yes
No
Does your Spouse/Partner have a history of congestive heart failure?
Please Select
Yes
No
Does your Spouse/Partner have a history of transient ischemic attack?
Please Select
Yes
No
Your Spouse/Partner's typical fasting blood sugar rate
mg/dL
Your Spouse/Partner's most recent A1C hemoglobin test
Percentage
Does your Spouse/Partner have a history of neuropathy, tingling, numbness, or pain in arms or legs?
Please Select
Yes
No
Has your Spouse/Partner experienced skin ulcers?
Please Select
Yes
No
Has your Spouse/Partner experienced kidney, vascular, or circulation problems?
Please Select
Yes
No
Has your Spouse/Partner experienced vision problems?
Please Select
Yes
No
Back
Next
Save
Cancer History
Have you been diagnosed with cancer?
Yes
No
Age at diagnosis
Type of cancer
Diagnosed stage
0 - 4
Do you have positive lymph nodes?
Yes
No
Cancer treatments
Chemotherapy
Radiation
Surgery
Seed Implants
Other
Is treatment continuing?
Yes
No
If treatment has ended, when did it conclude?
-
Month
-
Day
Year
Date
Spouse/Partner Cancer History
Has your Spouse/Partner been diagnosed with cancer?
Yes
No
Age at diagnosis
Type of cancer
Diagnosed stage
0 - 4
Does your Spouse/Partner have positive lymph nodes?
Yes
No
Cancer treatments
Chemotherapy
Radiation
Surgery
Seed Implants
Other
Is treatment continuing?
Yes
No
If treatment has ended, when did it conclude?
-
Month
-
Day
Year
Date
Back
Next
Save
Miscellaneous Health Questions
Have you spoken with your physician about memory loss in the past 5 years?
Yes
No
Do you have sleep apnea?
Yes
No
Do you use a CPAP machine?
Yes
No
What year did you start using the CPAP machine?
-
Month
-
Day
Year
Date
Spouse/Partner Miscellaneous Health Questions
Has your Spouse/Partner spoken with your physician about memory loss in the past 5 years?
Yes
No
Does your Spouse/Partner have sleep apnea?
Yes
No
Does your Spouse/Partner use a CPAP machine?
Yes
No
What year did your Spouse/Partner start using the CPAP machine?
-
Month
-
Day
Year
Date
Back
Next
Save
Additional Health Information
These are important questions to help me to recommend the appropriate plan with an LTC company to offer you long-term care benefits. Are there current health issues you know where a lab test, physical therapy, outpatient surgery, a known health issue, or a doctor's visit is recommended, i.e., Crohn's disease, Covid, urinalysis, back issues, or other specific health issues?
Your Notes
*
Describe other information here
Spouse/Partner Notes
*
Describe other information for your Spouse/Partner here
Back
Next
Save
Financial Baseline
What is your employment status?
Please Select
Employed
Self-employed
Part-time
Unemployed
Retired
What is your occupation?
If you are self-employed, is the business incorporated?
Yes
No
Are you an active/retired federal government/military employee?
Yes
No
Does your employer offer a long term care plan?
Yes
No
Not sure
Do you have a retirement plan?
Yes
No
Do you have a financial advisor?
Yes
No
Do you have investments or savings?
Yes
No
Do you have an individual retirement account?
Yes
No
Do you have a health directive and durable power of attorney?
Yes
No
Are there assets not needed for retirement that may be transferred to an LTC plan?
Yes
No
Examples may include, life insurance cash value, annuity, CD, cash, or other liquid assets.
Does your company offer an HSA benefit?
Yes
No
Spouse/Partner Financial Information
What is your Spouse/Partner employment status?
Please Select
Employed
Self-employed
Part-time
Unemployed
Retired
What is your Spouse/Partner's occupation?
If your Spouse/Partner is self-employed, is the business incorporated?
Yes
No
Is your Spouse/Partner an active/retired federal government/military employee?
Yes
No
Does your Spouse/Partner employer offer a long term care plan?
Yes
No
Not sure
Does your Spouse/Partner have a retirement plan?
Yes
No
Does your Spouse/Partner have a financial advisor?
Yes
No
Does your Spouse/Partner have investments or savings?
Yes
No
Does your Spouse/Partner have an individual retirement account?
Yes
No
Might any of these assets be transferred to an LTC plan?
Yes
No
Does your Spouse/Partner have a health directive and durable power of attorney?
Yes
No
Are there assets not needed for retirement that may be transferred to an LTC plan?
Yes
No
Examples may include, life insurance cash value, annuity, CD, cash, or other liquid assets.
Does your Spouse/Partner's company offer an HSA benefit?
Yes
No
Back
Next
Save
Final Thoughts
Why are you looking into extended care plans?
Please Select
Financial advisor recommended
Family or friend recommended
Previous experience
Read information on the internet
Newspaper or magazine article
Considered previously, but didn't act
Other/Don't Recall
Select best option
If you considered purchasing a plan previously, but didn’t make the purchase, please describe the circumstances
Additional Comments
Please verify that you are human
*
Heading
Email
example@example.com
Print
Save
Submit
Should be Empty: