Long Term Care Questionnaire

Long Term Care Questionnaire
2213 E Grand River Ave Suite B Lansing, MI 48912 844-705-3289

Ryan Heintz - Account Executive Edge Insurance Group
CLIENT INFORMATION
CLIENT NAME
Gender

MaleFemale
Date of Birth
State of Residence
Tobacco User

YesNo
Type of Tobacco
Height / Weight
Phone Number
Marital Status

SingleMarriedDivorced/Widowed
SPOUSE'S NAME
Gender

MaleFemale
Spouse Date of Birth
State of Residence
Tobacco User

YesNo
Type of Tobacco
Height / Weight
Phone Number
MEDICATIONS
Please list all current medications along with their purpose, dosage, length of usage, and number of times per day
HOSPITALIZATIONS
Please list all hospitalizations in the past 5 years, including dates and reason

MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MEDICAL HISTORY (specific to underwriting for long term care)
Long Term Care Supplemental Questionnaire
1. Do you currently use any of the following:

Quad CaneWheelchairStair LiftWalkerElectric ScooterHospital BedRespirator Oxygen (Including supp. CPAP use)
2. Do you currently need assistance with any of the following:

BathingToiletingDressingEatingMedication ManagementGetting In/Out of Bed/ChairBowel/Bladder Control
3. Have you ever been treated for any of the following conditions:

Alzheimer's CognitiveDementiaMemory Loss Huntington'sImpairment ALSOrganic Brain SyndromeMultiple SclerosisMuscular DystrophyParkinson'sParalysisMultiple MyelomaCerebral PalsyOrgan Transplant(other than kidney)HIV
4. Have you been diagnosed with any of the following conditions?
COPD Asthma Bronchitis

YesNo
Date of diagnosis Hospitalization(s)

MonthDayYear
Date
Treatment
Crohn's Colitis Diverticulitis

YesNo
Date of Last Flare-Up

MonthDayYear
Date
Date of Diagnosis Treatment

MonthDayYear
Date
Osteoporosis

YesNo
If Yes, Date of Diagnosis Treatment

MonthDayYear
Date
Most Recent Bone Density Score
Arthritis

YesNo
If Yes, What Type?
Date of diagnosis? Restrictions?

MonthDayYear
Date
Joint Replacements? Injections?
Fibromyalgia

YesNo
Date of diagnosis and list any limitations

MonthDayYear
Date
Treatment(s)
Lupus

YesNo
If Yes, What Type? SLE Discoid
Date of diagnosis Treatment

MonthDayYear
Date
5. Are you currently receiving Physical Therapy?

YesNo
If yes, explain
6. Are you currently receiving any type of joint injections?

YesNo
If yes, explain
7. Do you have any musculoskeletal conditions?

YesNo
If Yes, What Type and Date of Diagnosis
Current Treatment(s)
8. Do you currently take any narcotic medications for pain?

YesNo
If Yes, What is the Pain Causing Condition(s)?
Medication Name(s), Dosage, and Frequency
9. Have You Ever Been Diagnosed with:

DepressionAnxietyBipolar Conditions
If Yes, Date of Diagnosis

MonthDayYear
Date
10. Are you currently collecting disability?

YesNo
If Yes:

Private DisabilitySocial Security Income
11. If Retired, Did You Collect SSI and go Directly to SS?

YesNo
12. Have You Been Declined for Long Term Care Insurance (LTC) or a LTC Rider in the Past?

YesNo
If yes, date of decline

MonthDayYear
Date
Client Signature:
Signature

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Date
Spouse's Signature:
Signature

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Date
Should be Empty:

Long Term Care Questionnaire

CLIENT INFORMATION

MEDICATIONS

HOSPITALIZATIONS

Long Term Care Supplemental Questionnaire

Client Signature:

Spouse's Signature: