LTC Intake Form

  • Long-Term Care Intake Form

    Please Fill Out The Following Information To Receive Your Complimentary Long-Term Care Insurance Quote.
  • Format: (000) 000-0000.

  • Preliminary Health Questions

  • 1) Are you currently hospitalized, confined to a bed, or residing in an Assisted Living Facility?
  • 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?

  • 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
  • Home Health care services
  • Adult Day Care services
  • Walker, Wheelchair, Multi-prong cane, Motorized Scooter
  • Hospital bed
  • Hospital bed
  • Oxygen
  • Stair Lift
  • Dialysis machine
  • Hospice Care

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

  • Taking medication
  • Eating
  • Bathing
  • Managing your bowel or bladder
  • Toileting
  • Walking
  • Dressing
  • Getting in or out of a chair or bed

  • 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
  • Recurrent memory loss
  • Mild cognitive impairment (MCI)
  • Organic brain syndrome
  • Mental incapacity
  • Multiple sclerosis
  • Parkinson’s disease
  • Paralysis
  • Organ transplant other than cornea or kidney
  • Spinal Stenosis or Chronic Back pain with use of narcotic medication
  • Autoimmune disorder/disease such as Systemic Lupus, Systemic Scleroderma, CREST Syndrome, Connective Tissue disease, Mixed Connective Tissue disease
  • Muscular dystrophy
  • Lou Gehrig’s disease (ALS)
  • Huntington’s disease
  • Cirrhosis
  • Hepatitis
  • Stroke or Multiple Transient Ischemic Attack (TIA)
  • Smoking in conjunction with Emphysema, COPD

  • 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
  • Heart bypass surgery Heart valve replacement Vascular surgery
  • Been hospitalized overnight 2 or more times
  • Had any fall resulting in a fracture Had multiple falls
  • Had a seizure or convulsion
  • Tremors
  • Congestive heart failure Cardiomyopathy

  • 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
  • Hodgkin’s disease or other lymphoma
  • Any cancer other than non-melanoma skin cancer?
  • Alcohol or drug abuse or dependency
  • Hospitalization for depression, bi-polar disorder or any other psychiatric disorder
  • Blood clotting deficiency, Factor V, VII, VIII, IX, X,
  • Idiopathic thrombocytopenic purpura (ITP) or essential thrombocythemia
  • Von Willebrand disease
  • Smoking with peripheral vascular disease, diabetes, or renal disease

  • 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
  • Chronic kidney failure
  • Diabetes currently treated with insulin
  • Rheumatoid arthritis with joint deformity Rheumatoid arthritis with joint replacement Rheumatoid arthritis requiring use of narcotic medication
  • Kidney or cornea transplant
  • Myasthenia gravis
  • Diabetes with a history of TIA, Stroke, Neuropathy, kidney disease, peripheral vascular disease or congestive heart failure
  • Bipolar disorder, schizophrenia or other psychosis
  • 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?
  • Date of Birth
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  • Landmark 828

    828-966-3742 insurance.gal@hotmail.com
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