LTC Intake Form

Long-Term Care Intake Form

Please Fill Out The Following Information To Receive Your Complimentary Long-Term Care Insurance Quote.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Zip Code
Preliminary Health Questions
1) Are you currently hospitalized, confined to a bed, or residing in an Assisted Living Facility?

YESNO
2) In the last 12 months have you applied for any long term care policy or long term care rider that was declined or postponed?

YESNO
3) Are you currently using, or in the past 12 months have you used or been medically advised by a Healthcare Professional to use any of the following?
Care in a nursing facility

YESNO
Home Health care services

YESNO
Adult Day Care services

YESNO
Walker, Wheelchair, Multi-prong cane, Motorized Scooter

YESNO
Hospital bed

YESNO
Hospital bed

YESNO
Oxygen

YESNO
Stair Lift

YESNO
Dialysis machine

YESNO
Hospice Care

YESNO
4) Do you require assistance or supervision in performing any of the following activities?
Taking medication

YESNO
Eating

YESNO
Bathing

YESNO
Managing your bowel or bladder

YESNO
Toileting

YESNO
Walking

YESNO
Dressing

YESNO
Getting in or out of a chair or bed

YESNO
5) In the last 7 years, have you had, been diagnosed or treated by a Health Care Professional, been prescribed or taken medication for any of the following?
Alzheimer’s disease or dementia

YESNO
Recurrent memory loss

YESNO
Mild cognitive impairment (MCI)

YESNO
Organic brain syndrome

YESNO
Mental incapacity

YESNO
Multiple sclerosis

YESNO
Parkinson’s disease

YESNO
Paralysis

YESNO
Organ transplant other than cornea or kidney

YESNO
Spinal Stenosis or Chronic Back pain with use of narcotic medication

YESNO
Autoimmune disorder/disease such as Systemic Lupus, Systemic Scleroderma, CREST Syndrome, Connective Tissue disease, Mixed Connective Tissue disease

YESNO
Muscular dystrophy

YESNO
Lou Gehrig’s disease (ALS)

YESNO
Huntington’s disease

YESNO
Cirrhosis

YESNO
Hepatitis

YESNO
Stroke or Multiple Transient Ischemic Attack (TIA)

YESNO
Smoking in conjunction with Emphysema, COPD

YESNO
6) In the last 12 months have you had, been diagnosed or treated by a Healthcare Professional, or been prescribed or taken medication for any of the following?
Aneurysm

YESNO
Heart bypass surgery Heart valve replacement Vascular surgery

YESNO
Been hospitalized overnight 2 or more times

YESNO
Had any fall resulting in a fracture Had multiple falls

YESNO
Had a seizure or convulsion

YESNO
Tremors

YESNO
Congestive heart failure Cardiomyopathy

YESNO
7) In the last 5 years, have you had, been diagnosed or treated by a Healthcare Professional, or been prescribed or taken medication for any of the following?
Leukemia

YESNO
Hodgkin’s disease or other lymphoma

YESNO
Any cancer other than non-melanoma skin cancer?

YESNO
Alcohol or drug abuse or dependency

YESNO
Hospitalization for depression, bi-polar disorder or any other psychiatric disorder

YESNO
Blood clotting deficiency, Factor V, VII, VIII, IX, X,

YESNO
Idiopathic thrombocytopenic purpura (ITP) or essential thrombocythemia

YESNO
Von Willebrand disease

YESNO
Smoking with peripheral vascular disease, diabetes, or renal disease

YESNO
7) In the last 7 years, have you had, been diagnosed or treated by a Healthcare Professional, or been prescribed or taken medication for any of the following?
TIA with a history of heart disease

YESNO
Chronic kidney failure

YESNO
Diabetes currently treated with insulin

YESNO
Rheumatoid arthritis with joint deformity Rheumatoid arthritis with joint replacement Rheumatoid arthritis requiring use of narcotic medication

YESNO
Kidney or cornea transplant

YESNO
Myasthenia gravis

YESNO
Diabetes with a history of TIA, Stroke, Neuropathy, kidney disease, peripheral vascular disease or congestive heart failure

YESNO
Bipolar disorder, schizophrenia or other psychosis

YESNO
9) Have you been medically advised by a Healthcare Professional to have any surgery, nonroutine diagnostic test or medical evaluation that has not yet been completed?

YESNO
9) Additional Information (If any of the above questions are answered “Yes,” please list all medications)
HEIGHT AND WEIGHT
Date of Birth

MonthDayYear
Landmark 828

828-966-3742 insurance.gal@hotmail.com
Should be Empty:

Long-Term Care Intake Form

Preliminary Health Questions

Landmark 828