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.
Would you like to include your spouse/partner in this assessment?
*
YES, I would like to include my spouse/partner in this assessment.
NO, I am single or do not want to include my spouse/partner in this assessment.
Full 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
Date of Birth
-
Month
-
Day
Year
Date
Phone number
Format: (000) 000-0000.
How did you find us?
Please Select
Facebook
Google
Friend/Family
Wealth Advisor
Other
What are your concerns that you are considering LTC Benefits?
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Spouse or Partner Information
Spouse or Partner Information
Spouse/Partner full name
First Name
Last Name
Spouse Email
Spouse 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
Spouse Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse Date of Birth
-
Month
-
Day
Year
Date
Spouse Phone number
Format: (000) 000-0000.
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Your Personal Details
Your Personal Details
Gender
Please Select
Male
Female
Choose not to identify
Weight and Height
*
Tobacco Use
Yes
No
Spouse/Partner Personal Details
Spouse/Partner Personal Details
Spouse/Partner Gender
Please Select
Male
Female
Choose not to identify
Spouse/Partner Weight and Height
Tobacco Use
Yes
No
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Medical Details
Medical Details
Complete information for you and your spouse/partner (if applicable).
Primary care physician
Enter their full name here
Physician Email
*
example@example.com
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Spouse/Partner Medical Details
Spouse/Partner Medical Details
Spouse/Partner primary care physician
Enter their full name here
Spouse/Partner Physician Email
example@example.com
Spouse/Partner Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Medical History
Complete information for you and/or your spouse/partner. Where applicable, you may add more than one row of information per question by clicking the add button.
Medical Specialists Information
Please list any medical specialists you and/or your spouse/partner have seen in the past 5 years. If you have seen more than 3 specialists within the past 5 years, list the most recent 3 here.
Medical Test History
Please list any medical tests (blood work, CAT scan, etc.) you and/or your spouse/partner have had in the past 12 months and the results. If you have had more than 3 tests within the past 12 months, list the most recent 3 here.
Medications
Please list any medications that you and/or your spouse/partner are currently using.
Medications Not Taken
Please list any medications a physician has prescribed but that you and/or your spouse/partner are not taking.
Surgeries
Please list surgeries here.
When was your last prostate exam
-
Month
-
Day
Year
Date
When was your Spouse/Partner's last prostate exam
-
Month
-
Day
Year
Date
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
Medical History (continued)
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
Rows
Yes
Year Diagnosed
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
Rows
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
Skeletal Health
Choose yes or not option for each option.
Joint replacement conducted or recommended in the last 5 years?
Yes
No
Have you had cortisone or other joint injections in the last 5 years?
Yes
No
Do you have any joint deformities?
Yes
No
Do you use any mobility aids such as a walker or crutches?
Yes
No
Spouse/Partner Skeletal Health
Spouse/Partner Skeletal Health
Optional - Choose yes or not option for each option.
Has your spouse/partner had any joint replacement conducted or recommended in the last 5 years?
Yes
No
Has your spouse/partner had any cortisone or other joint injections in the last 5 years?
Yes
No
Does your spouse/partner you have any joint deformities?
Yes
No
Do your spouse/partner use any mobility aids such as a walker or crutches?
Yes
No
HIV/AIDS Questions
HIV/AIDS Questions
Choose yes or not option for each option. Please provide more details if you are positive.
Have you been diagnosed as having AIDS?
Yes
No
Have you been diagnosed as having AIDS Related Complex (ARC)?
Yes
No
Have you been diagnosed as having HIV (symptomatic or asymptomatic)?
Yes
No
Please provide additional details about your HIV/AIDs diagnosis
Enter details here
Spouse/Partner HIV/AID Questions
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?
Yes
No
Has your Spouse/Partner been diagnosed as having AIDS Related Complex (ARC)?
Yes
No
Has your Spouse/Partner been diagnosed as having HIV (symptomatic or asymptomatic)?
Yes
No
Please provide additional details about your Spouse/Partner HIV/AIDs diagnosis
Enter details here
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Applicant Mobility and Disability Questions
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?
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?
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?
Yes
No
Have you ever been on disability?
Yes
No
Have you ever been declined for long term care insurance?
Yes
No
If you selected Yes for any of the Mobility questions, please elaborate.
Spouse/Partner Applicant Mobility and Disability Questions
Spouse/Partner Applicant Mobility and Disability Questions
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?
Yes
No
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?
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?
Yes
No
Has your Spouse/Partner ever been on disability?
Yes
No
Has your Spouse/Partner ever been declined for long term care insurance?
Yes
No
If your Spouse/Partner was Yes for any of the Mobility questions, please elaborate.
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Questions About Diabetes
Questions About Diabetes
Have you been diagnosed with diabetes?
Yes
No
Age at diagnosis
Do you have a history of stroke?
Yes
No
Do you have a history of transient ischemic attack?
Yes
No
Do you have a history of congestive heart failure?
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?
Yes
No
Have you experienced skin ulcers?
Yes
No
Have you experienced kidney, vascular, or circulation problems?
Yes
No
Have you experienced vision problems?
Yes
No
Questions About Partner/Spouse Diabetes
Questions About Partner/Spouse Diabetes
Has your Spouse/Partner been diagnosed with diabetes?
Yes
No
Age at diagnosis (Spouse/Partner)
Do your Spouse/Partner have a history of stroke?
Yes
No
Does your Spouse/Partner have a history of congestive heart failure?
Yes
No
Does your Spouse/Partner have a history of transient ischemic attack?
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?
Yes
No
Has your Spouse/Partner experienced skin ulcers?
Yes
No
Has your Spouse/Partner experienced kidney, vascular, or circulation problems?
Yes
No
Has your Spouse/Partner experienced vision problems?
Yes
No
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Cancer History
Cancer History
Have you been diagnosed with cancer?
Yes
No
Age at diagnosis
Type of cancer
Diagnosed stage
Stage 0
Stage I (1)
Stage II (2)
Stage III (3)
Stage IV (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
Spouse/Partner Cancer History
Has your Spouse/Partner been diagnosed with cancer?
Yes
No
Age at diagnosis
Type of cancer
Diagnosed stage
Stage 0
Stage I (1)
Stage II (2)
Stage III (3)
Stage IV (4)
Does your Spouse/Partner have positive lymph nodes?
Yes
No
Cancer treatments
Chemotherapy
Radiation
Surgery
Seed Implants
Other
Is treatment continuing? (spouse)
Yes
No
If treatment has ended, when did it conclude? (spouse)
-
Month
-
Day
Year
Date
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Miscellaneous Health Questions
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
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
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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
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Financial Baseline
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
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
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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
*
Email
example@example.com
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