Performance Health PHQ (Interlutions)

PHQ: Personal Health Questionnaire

Applying for enrollment in an Affinity Health Plan
Name*

First NameLast Name
Company Name*
If self-employed, list self.
Email*
example@example.com
Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Requested start date for coverage*

MonthDayYear
Date
Pharmacy Assistance Program Income Qualification Please input the range of your pre-tax household yearly income.*

25K - 50K50K - 75K75K - 100K100K - 150K150K - 200K200K+
How many people are in your household*
Enter # of household residents.
I. Demographic Build & Tobacco Use
- Answer all of the following questions for yourself and enrolling family members.
- All questions must be answered, or the form may not be accepted.
Social Security Number*
Gender at Birth*
Date of Birth*

MonthDayYear
Date
Height *

FeetInches
Weight*
Pounds
Tobacco use in the last Year*

YESNO
Are you adding a Spouse/Domestic Partner?*

YESNO
Name (Spouse)*

First NameLast Name
Date of Birth (Spouse)*

MonthDayYear
Social Security Number (Spouse)*
Gender at birth (Spouse)*
Zip Code (Spouse)*
Height *

FeetInches
Weight*
Pounds
Tobacco use in the last year*

YESNO
Are you adding Child/Children?*

YESNO
Child's Name (1)*

First NameLast Name
Date of Birth (1)*

MonthDayYear
Date
Social Security Number (1)*
Gender at Birth (1)*
Zip Code (1)*
Height (1)*

FeetInches
Weight (1)*
Pounds
Tobacco use in the last year? (1)*

YESNO
Add Second Child?*

YESNO
Child's Name (2)*

First NameLast Name
Date of Birth (2)*

MonthDayYear
Date
Social Security Number (2)*
Gender at Birth (2)*
Zip Code (2)*
Height (2)*

FeetInches
Weight (2)*
Pounds
Tobacco use in the last year? (2)*

YESNO
Add Third Child?*

YESNO
Child's Name (3)*

First NameLast Name
Date of Birth (3)*

MonthDayYear
Date
Social Security Number (3)*
Gender at Birth (3)*
Zip Code (3)*
Height (3)*

FeetInches
Weight (3)*
Pounds
Tobacco use in the last year? (3)*

YESNO
Add Fourth Child?*

YESNO
Child's Name (4)*

First NameLast Name
Date of Birth (4)*

MonthDayYear
Date
Social Security Number (4)*
Gender at Birth (4)*
Zip Code (4)*
Height (4)*

FeetInches
Weight (4)*
Pounds
Tobacco use in the last year? (4)*

YESNO
Add Fifth Child?*

YESNO
Child's Name (5)*

First NameLast Name
Date of Birth (5)*

MonthDayYear
Date
Social Security Number (5)*
Gender at Birth (5)*
Zip Code (5)*
Height (5)*

FeetInches
Weight (5)*
Pounds
Tobacco use in the last year? (5)*

YESNO
Add Sixth Child?*

YESNO
Child's Name (6)*

First NameLast Name
Date of Birth (6)*

MonthDayYear
Date
Social Security Number (6)*
Gender at Birth (6)*
Zip Code (6)*
Height (6)*

FeetInches
Weight (6)*
Pounds
Tobacco use in the last year? (6)*

YESNO
Add Seventh Child?*

YESNO
Child's Name (7)*

First NameLast Name
Date of Birth (7)*

MonthDayYear
Date
Social Security Number (7)*
Gender at Birth (7)*
Zip Code (7)*
Height (7)*

FeetInches
Weight (7)*
Pounds
Tobacco use in the last year? (7)*

YESNO
II. Medical Conditions & Treatments
Has any person listed above seen a medical provider, had treatment recommended, received care (including prescriptions) or been hospitalized for any of the following within the last 5 years?

Check 'YES' or 'NO' for each question.
Please complete ADDITIONAL DETAIL SECTION for ALL 'Yes' answers
1. Cancer*

YESNO
1. Cancer*
1.Date of Onset*

MonthDayYear
Date
1. Condition/Diagnosis*
Check One*

Stage 1Stage 2Stage 3Stage 4 or Higher
1. Last treated Date*

MonthDayYear
Date
1. Treatment/Drug*
1. Still Taking?*

YESNO
1. Degree of Recovery*
Add additional family member?*

YESNO
1a. Cancer*
1a.Date of Onset*

MonthDayYear
Date
1a. Condition/Diagnosis*
Check One*

Stage 1Stage 2Stage 3Stage 4 or Higher
1a. Last treated Date*

MonthDayYear
Date
1a. Treatment/Drug*
1a. Still Taking?*

YESNO
1a. Degree of Recovery*
2. Cardiac or Heart Disease/Disorder*

YESNO
2. Cardiac or Heart Disease*
2. Date of Onset*

MonthDayYear
Date
2. Condition/Diagnosis*
Check all that apply*

Heart AttackBypass surgery or angioplasty on single vesselBypass surgery on multiple vesselsOther
2. Last treated Date*

MonthDayYear
Date
2. Treatment/Drug*
2. Still Taking?*

YESNO
2. Degree of Recovery*
Add additional family members?*

YESNO
2a. Cardiac or Heart Disease*
2a. Date of Onset*

MonthDayYear
Date
2a. Condition/Diagnosis*
2a. Check all that apply*

Heart AttackBypass surgery or angioplasty on single vesselBypass surgery on multiple vesselsOther
2a. Last treated Date*

MonthDayYear
Date
2a. Treatment/Drug*
2a. Still Taking?*

YESNO
2a. Degree of Recovery*
3. Diabetes*

YESNO
3. Diabetes*
3. Date of Onset*

MonthDayYear
Date
3. List the three most recent HbA1c/fasting blood sugar levels*

1) Blood Sugar Level2) Blood Sugar Level3) Blood Sugar Level
3. Condition/Diagnosis*
3. Last treated Date*

MonthDayYear
Date
3. Treatment/Drug*
3. Still Taking?*

YESNO
3. Degree of Recovery*
Add additional family members?*

YESNO
3a. Diabetes*
3a. Date of Onset*

MonthDayYear
Date
3a. List the three most recent HbA1c/fasting blood sugar levels*

1) Blood Sugar Level2) Blood Sugar Level3) Blood Sugar Level
3a. Condition/Diagnosis*
3a. Last treated Date*

MonthDayYear
Date
3a. Treatment/Drug*
3a. Still Taking?*

YESNO
3a. Degree of Recovery*
4. High Cholesterol*

YESNO
4. High Cholesterol*
4. Date of Onset*

MonthDayYear
Date
4. List the three most recent Cholesterol readings:*

1) Cholesterol2) Cholesterol3) Cholesterol
4. Condition/Diagnosis*
4. Last treated Date*

MonthDayYear
Date
4. Treatment/Drug*
4. Still Taking?*

YESNO
4. Degree of Recovery*
Add additional family members?*

YESNO
4a. High Cholesterol*
4a. Date of Onset*

MonthDayYear
Date
4a. List the three most recent Cholesterol readings:*

1) Cholesterol2) Cholesterol3) Cholesterol
4a. Condition/Diagnosis*
4a. Last treated Date*

MonthDayYear
Date
4a. Treatment/Drug*
4a. Still Taking?*

YESNO
4a. Degree of Recovery*
5. High Blood Pressure*

YESNO
5. High Blood Pressure*
5. Date of Onset*

MonthDayYear
Date
5. List the three most recent readings:

1) HBP2) HBP3) HBP
5. Condition/Diagnosis*
5. Last treated Date*

MonthDayYear
Date
5. Treatment/Drug*
5. Still Taking?*

YESNO
5. Degree of Recovery*
Add additional family members?*

YESNO
5a. High Blood Pressure*
5a. Date of Onset*

MonthDayYear
Date
5a. List the three most recent readings:

1) HBP2) HBP3) HBP
5a. Condition/Diagnosis*
5a. Last treated Date*

MonthDayYear
Date
5a. Treatment/Drug*
5a. Still Taking?*

YESNO
5a. Degree of Recovery*
6. Arthritis (i.e. rheumatoid, osteo, psoriatic, gout)*

YESNO
6. Arthritis*
6. Condition/Diagnosis*
6. Date of Onset*

MonthDayYear
Date
6. Last treated Date*

MonthDayYear
Date
6.Treatment/Drug*
6. Still Taking?*

YESNO
6. Degree of Recovery*
Add additional family members?*

YESNO
6a. Arthritis*
6a. Condition/Diagnosis*
6a. Date of Onset*

MonthDayYear
Date
6a. Last treated Date*

MonthDayYear
Date
6a.Treatment/Drug*
6a. Still Taking?*

YESNO
6a. Degree of Recovery*
7. Autoimmune Disease (i.e. lupus, MS, anemia)*

YESNO
7. Autoimmune Disease*
7. Condition/Diagnosis*
7. Date of Onset*

MonthDayYear
Date
7. Last treated Date*

MonthDayYear
Date
7. Treatment/Drug*
7. Still Taking?*

YESNO
7. Degree of Recovery*
Add additional family members?*

YESNO
7a. Autoimmune Disease*
7a. Condition/Diagnosis*
7a. Date of Onset*

MonthDayYear
Date
7a. Last treated Date*

MonthDayYear
Date
7a. Treatment/Drug*
7a. Still Taking?*

YESNO
7a. Degree of Recovery*
8. Back Disorder (i.e. degenerative disk disease, herniated disk, spinal fusion, spondylitis, strain)*

YESNO
8. Back Disorder*
8. Condition/Diagnosis*
8. Date of Onset*

MonthDayYear
Date
8. Last treated Date*

MonthDayYear
Date
8. Treatment/Drug*
8. Still Taking?*

YESNO
8. Degree of Recovery*
Add additional family members?*

YESNO
8a. Back Disorder*
8a. Condition/Diagnosis*
8a. Date of Onset*

MonthDayYear
Date
8a. Last treated Date*

MonthDayYear
Date
8a. Treatment/Drug*
8a. Still Taking?*

YESNO
8a. Degree of Recovery*
9. Benign Growth (i.e. tumor, cyst)*

YESNO
9. Benign Growth*
9. Condition/Diagnosis*
9. Date of Onset*

MonthDayYear
Date
9. Last treated Date*

MonthDayYear
Date
9. Treatment/Drug*
9. Still Taking?*

YESNO
9. Degree of Recovery*
Add additional family members?*

YESNO
9a. Benign Growth*
9a. Condition/Diagnosis*
9a. Date of Onset*

MonthDayYear
Date
9a. Last treated Date*

MonthDayYear
Date
9a. Treatment/Drug*
9a. Still Taking?*

YESNO
9a. Degree of Recovery*
10. Bowel (i.e. irritable bowel IBS, Crohn's ileitis)*

YESNO
10. Bowel*
10. Condition/Diagnosis*
10. Date of Onset*

MonthDayYear
Date
10. Last treated Date*

MonthDayYear
Date
10. Treatment/Drug*
10. Still Taking?*

YESNO
10. Degree of Recovery*
Add additional family members?*

YESNO
10a. Bowel*
10a. Condition/Diagnosis*
10a. Date of Onset*

MonthDayYear
Date
10a. Last treated Date*

MonthDayYear
Date
10a. Treatment/Drug*
10a. Still Taking?*

YESNO
10a. Degree of Recovery*
11. Circulatory System Disease (i.e. stroke, arterial / vascular diseases)*

YESNO
11. Circulatory System Disease*
11. Condition/Diagnosis*
11. Date of Onset*

MonthDayYear
Date
11. Last treated Date*

MonthDayYear
Date
11. Treatment/Drug*
11. Still Taking?*

YESNO
11. Degree of Recovery*
Add additional family members?*

YESNO
11a. Circulatory System Disease*
11a. Condition/Diagnosis*
11a. Date of Onset*

MonthDayYear
Date
11a. Last treated Date*

MonthDayYear
Date
11a. Treatment/Drug*
11a. Still Taking?*

YESNO
11a. Degree of Recovery*
12. Immunodeficiency (i.e. AIDS, HIV+, hemophilia)*

YESNO
12. Immunodeficiency*
12. Condition/Diagnosis*
12. Date of Onset*

MonthDayYear
Date
12. Last treated Date*

MonthDayYear
Date
12. Treatment/Drug*
12. Still Taking?*

YESNO
12. Degree of Recovery*
Add additional family members?*

YESNO
12a. Immunodeficiency*
12a. Condition/Diagnosis*
12a. Date of Onset*

MonthDayYear
Date
12a. Last treated Date*

MonthDayYear
Date
12a. Treatment/Drug*
12a. Still Taking?*

YESNO
12a. Degree of Recovery*
13. Kidney Disorder (i.e. nephritis, renal failure)*

YESNO
13. Kidney*
13. Condition/Diagnosis*
13. Date of Onset*

MonthDayYear
Date
13. Last treated Date*

MonthDayYear
Date
13. Treatment/Drug*
13. Still Taking?*

YESNO
13. Degree of Recovery*
Add additional family members?*

YESNO
13a. Kidney*
13a. Condition/Diagnosis*
13a. Date of Onset*

MonthDayYear
Date
13a. Last treated Date*

MonthDayYear
Date
13a. Treatment/Drug*
13a. Still Taking?*

YESNO
13a. Degree of Recovery*
14. Liver Disease (i.e. cirrhosis, hepatitis A, B, C, E)*

YESNO
14. Liver Disease*
14. Condition/Diagnosis*
14. Date of Onset*

MonthDayYear
Date
14. Last treated Date*

MonthDayYear
Date
14. Treatment/Drug*
14. Still Taking?*

YESNO
14. Degree of Recovery*
Add additional family members?*

YESNO
14a. Liver Disease*
14a. Condition/Diagnosis*
14a. Date of Onset*

MonthDayYear
Date
14a. Last treated Date*

MonthDayYear
Date
14a. Treatment/Drug*
14a. Still Taking?*

YESNO
14a. Degree of Recovery*
15. Mental Illness (i.e. mild or major depression, anxiety, bipolar disorder, or schizophrenia)*

YESNO
15. Mental Illness*
15. Condition/Diagnosis*
15. Date of Onset*

MonthDayYear
Date
15. Last treated Date*

MonthDayYear
Date
15. Treatment/Drug*
15. Still Taking?*

YESNO
15. Degree of Recovery*
Add additional family members?*

YESNO
15a. Mental Illness*
15a. Condition/Diagnosis*
15a. Date of Onset*

MonthDayYear
Date
15a. Last treated Date*

MonthDayYear
Date
15a. Treatment/Drug*
15a. Still Taking?*

YESNO
15a. Degree of Recovery*
16. Counseling (Current or prior counseling?)*

YESNO
16. Counseling*
16. Condition/Diagnosis*
16. Date of Onset*

MonthDayYear
Date
16. Last treated Date*

MonthDayYear
Date
16. Treatment/Drug*
16. Still Taking?*

YESNO
16. Degree of Recovery*
Add additional family members?*

YESNO
16a. Counseling*
16a. Condition/Diagnosis*
16a. Date of Onset*

MonthDayYear
Date
16a. Last treated Date*

MonthDayYear
Date
16a. Treatment/Drug*
16a. Still Taking?*

YESNO
16a. Degree of Recovery*
17. Muscular Disorder*

YESNO
17. Muscular Disorder*
17. Condition/Diagnosis*
17. Date of Onset*

MonthDayYear
Date
17. Last treated Date*

MonthDayYear
Date
17. Treatment/Drug*
17. Still Taking?*

YESNO
17. Degree of Recovery*
Add additional family members?*

YESNO
17a. Muscular Disorder*
17a. Condition/Diagnosis*
17a. Date of Onset*

MonthDayYear
Date
17a. Last treated Date*

MonthDayYear
Date
17a. Treatment/Drug*
17a. Still Taking?*

YESNO
17a. Degree of Recovery*
18. Respiratory (i.e. asthma, allergies, pneumonia, COPD, emphysema, bronchitis)*

YESNO
18. Respiratory*
18. Condition/Diagnosis*
18. Date of Onset*

MonthDayYear
Date
18. Last treated Date*

MonthDayYear
Date
18. Treatment/Drug*
18. Still Taking?*

YESNO
18. Degree of Recovery*
Add additional family members?*

YESNO
18a. Respiratory*
18a. Condition/Diagnosis*
18a. Date of Onset*

MonthDayYear
Date
18a. Last treated Date*

MonthDayYear
Date
18a. Treatment/Drug*
18a. Still Taking?*

YESNO
18a. Degree of Recovery*
19. Stomach (i.e. ulcer, acid reflux, GERD)*

YESNO
19. Stomach*
19. Condition/Diagnosis*
19. Date of Onset*

MonthDayYear
Date
19. Last treated Date*

MonthDayYear
Date
19. Treatment/Drug*
19. Still Taking?*

YESNO
19. Degree of Recovery*
Add additional family members?*

YESNO
19a. Stomach*
19a. Condition/Diagnosis*
19a. Date of Onset*

MonthDayYear
Date
19a. Last treated Date*

MonthDayYear
Date
19a. Treatment/Drug*
19a. Still Taking?*

YESNO
19a. Degree of Recovery*
20. Substance dependency (i.e. alcohol, drug)*

YESNO
20. Substance Dependency *
20. Condition/Diagnosis*
20. Date of Onset*

MonthDayYear
Date
20. Last treated Date*

MonthDayYear
Date
20. Treatment/Drug*
20. Still Taking?*

YESNO
20. Degree of Recovery*
Add additional family members?*

YESNO
20a. Substance Dependency *
20a. Condition/Diagnosis*
20a. Date of Onset*

MonthDayYear
Date
20a. Last treated Date*

MonthDayYear
Date
20a. Treatment/Drug*
20a. Still Taking?*

YESNO
20a. Degree of Recovery*
21. Transplants*

YESNO
21. Transplants*
List of Organs*
21. Condition/Diagnosis*
21. Date of Onset*

MonthDayYear
Date
21. Last treated Date*

MonthDayYear
Date
21. Treatment/Drug*
21. Still Taking?*

YESNO
21. Degree of Recovery*
Add additional family members?*

YESNO
21a. Transplants*
21a.List of Organs*
21a. Condition/Diagnosis*
21a. Date of Onset*

MonthDayYear
Date
21a. Last treated Date*

MonthDayYear
Date
21a. Treatment/Drug*
21a. Still Taking?*

YESNO
21a. Degree of Recovery*
22. Is anyone currently taking prescription medication(s)?*

YESNO
22. Prescription Medication*
22. Prescription Drug (1)*
22. Still Taking? (1)*

YESNO
22. Condition/Diagnosis (1)*
22. Date of Onset (1)*

MonthDayYear
Date
Add additional prescription medication(2)?*

YESNO
22. Prescription Drug (2)*
22. Still Taking? (2)*

YESNO
22. Condition/Diagnosis (2)*
22. Date of Onset (2)*

MonthDayYear
Date
Add additional prescription medication? (3)*

YESNO
22. Prescription Drug (3)*
22. Still Taking? (3)*

YESNO
22. Condition/Diagnosis (3)*
22. Date of Onset (3)*

MonthDayYear
Date
Add additional prescription medication? (4)*

YESNO
22. Prescription Drug (4)*
22. Still Taking? (4)*

YESNO
22. Condition/Diagnosis (4)*
22. Date of Onset (4)*

MonthDayYear
Date
22. Degree of Recovery*
Add additional family members?*

YESNO
22a. Prescription Medication*
22a. Prescription Drug (1)*
22a. Still Taking? (1)*

YESNO
22a. Condition/Diagnosis (1)*
22a. Date of Onset (1)*

MonthDayYear
Date
Add additional prescription medication(2)?*

YESNO
22a. Prescription Drug (2)*
22a. Still Taking? (2)*

YESNO
22a. Condition/Diagnosis (2)*
22a. Date of Onset (2)*

MonthDayYear
Date
Add additional prescription medication? (3)*

YESNO
22a. Prescription Drug (3)*
22a. Still Taking? (3)*

YESNO
22a. Condition/Diagnosis (3)*
22a. Date of Onset (3)*

MonthDayYear
Date
Add additional prescription medication? (4)*

YESNO
22a. Prescription Drug (4)*
22a. Still Taking? (4)*

YESNO
22a. Condition/Diagnosis (4)*
22a. Date of Onset (4)*

MonthDayYear
Date
22a. Degree of Recovery*
Add additional family members?*

YESNO
22b. Prescription Medication*
22b. Prescription Drug (1)*
22b. Still Taking? (1)*

YESNO
22b. Condition/Diagnosis (1)*
22b. Date of Onset (1)*

MonthDayYear
Date
Add additional prescription medication(2)?*

YESNO
22b. Prescription Drug (2)*
22b. Still Taking? (2)*

YESNO
22b. Condition/Diagnosis (2)*
22b. Date of Onset (2)*

MonthDayYear
Date
Add additional prescription medication? (3)*

YESNO
22b. Prescription Drug (3)*
22b. Still Taking? (3)*

YESNO
22b. Condition/Diagnosis (3)*
22b. Date of Onset (3)*

MonthDayYear
Date
Add additional prescription medication? (4)*

YESNO
22b. Prescription Drug (4)*
22b. Still Taking? (4)*

YESNO
22b. Condition/Diagnosis (4)*
22b. Date of Onset (4)*

MonthDayYear
Date
22a. Degree of Recovery*
23. Has anyone had any of the following for a serious illness in the past 5 years?*

a) Treatmentb) Hospitalizationc) Surgeryd) NO
23a. Treatment for Serious Illness in last 5 years *
23a. Condition/Diagnosis*
23a. Date of Onset*

MonthDayYear
Date
23a. Last treated Date*

MonthDayYear
Date
23a.Treatment/Drug*
23a. Still Taking?*

YESNO
23a. Degree of Recovery*
Add additional family members?*

YESNO
23a. Treatment for Serious Illness in last 5 years *
23a. Condition/Diagnosis*
23a. Date of Onset*

MonthDayYear
Date
23a. Last treated Date*

MonthDayYear
Date
23a.Treatment/Drug*
23a. Still Taking?*

YESNO
23a. Degree of Recovery*
23b. Hospitalization for serious illness in the last 5 year *
23b. Condition/Diagnosis*
23b. Date of Onset*

MonthDayYear
Date
23b. Last treated Date*

MonthDayYear
Date
23b. Treatment/Drug*
23b. Still Taking?*

YESNO
23. Degree of Recovery*
Add additional family members?*

YESNO
23b. Hospitalization for serious illness in the last 5 year *
23b. Condition/Diagnosis*
23b. Date of Onset*

MonthDayYear
Date
23b. Last treated Date*

MonthDayYear
Date
23b. Treatment/Drug*
23b. Still Taking?*

YESNO
23b. Degree of Recovery*
23c. Surgery for a serious illness in the last 5 years *
23c. Condition/Diagnosis*
23c. Date of Onset*

MonthDayYear
Date
23c. Last treated Date*

MonthDayYear
Date
23c. Treatment/Drug*
23c. Still Taking?*

YESNO
23c. Degree of Recovery*
Add additional family members?*

YESNO
23c. Surgery for a serious illness in the last 5 years *
23c. Condition/Diagnosis*
23c. Date of Onset*

MonthDayYear
Date
23c. Last treated Date*

MonthDayYear
Date
23c. Treatment/Drug*
23c. Still Taking?*

YESNO
23c. Degree of Recovery*
24. Is anyone currently Hospitalized or confined in a treatment facility?*

YESNO
24. Currently hospitalized or confined in a treatment facility*
24. Condition/Diagnosis*
24. Date of Onset*

MonthDayYear
Date
24. Last treated Date*

MonthDayYear
Date
24. Treatment/Drug*
24. Still Taking?*

YESNO
24. Degree of Recovery*
Add additional family members?*

YESNO
24a. Currently hospitalized or confined in a treatment facility*
24a. Condition/Diagnosis*
24a. Date of Onset*

MonthDayYear
Date
24a. Last treated Date*

MonthDayYear
Date
24a. Treatment/Drug*
24a. Still Taking?*

YESNO
24a. Degree of Recovery*
25. Is anyone currently confined at home, incapacitated or incapable of self-support?*

YESNO
25. Currently confined at home, incapacitated or incapable of self support*
25. Condition/Diagnosis*
25. Date of Onset*

MonthDayYear
Date
25. Last treated Date*

MonthDayYear
Date
25. Treatment/Drug*
25. Still Taking?*

YESNO
25. Degree of Recovery*
Add additional family members?*

YESNO
25a. Currently confined at home, incapacitated or incapable of self support*
25a. Condition/Diagnosis*
25a. Date of Onset*

MonthDayYear
Date
25a. Last treated Date*

MonthDayYear
Date
25a. Treatment/Drug*
25a. Still Taking?*

YESNO
25a. Degree of Recovery*
26. Pending treatment (medical treatment or diagnostic testing)*

YESNO
26. Pending Treatment (Medical or diagnostic)*
26. Condition/Diagnosis*
26. Date of Onset*

MonthDayYear
Date
26. Last treated Date*

MonthDayYear
Date
26. Treatment/Drug*
26. Still Taking?*

YESNO
26. Degree of Recovery*
Add additional family members?*

YESNO
26a. Pending Treatment (Medical or diagnostic)*
26a. Condition/Diagnosis*
26a. Date of Onset*

MonthDayYear
Date
26a. Last treated Date*

MonthDayYear
Date
26a. Treatment/Drug*
26a. Still Taking?*

YESNO
26a. Degree of Recovery*
27. Pending or upcoming hospitalization*

YESNO
27. Pending Hospitalization*
27. Condition/Diagnosis*
27. Date of Onset*

MonthDayYear
Date
27. Last treated Date*

MonthDayYear
Date
27. Treatment/Drug*
27. Still Taking?*

YESNO
27. Degree of Recovery*
Add additional family members?*

YESNO
27a. Pending Hospitalization*
27a. Condition/Diagnosis*
27a. Date of Onset*

MonthDayYear
Date
27a. Last treated Date*

MonthDayYear
Date
27a. Treatment/Drug*
27a. Still Taking?*

YESNO
27a. Degree of Recovery*
28. Pending or upcoming surgery*

YESNO
28. Pending Surgery*
28. Condition/Diagnosis*
28. Date of Onset*

MonthDayYear
Date
28. Last treated Date*

MonthDayYear
Date
28. Treatment/Drug*
28. Still Taking?*

YESNO
28. Degree of Recovery*
Add additional family members?*

YESNO
28a. Pending Surgery*
28a. Condition/Diagnosis*
28a. Date of Onset*

MonthDayYear
Date
28a. Last treated Date*

MonthDayYear
Date
28a. Treatment/Drug*
28a. Still Taking?*

YESNO
28a. Degree of Recovery*
29. In the past 5 years, has anyone enrolling had symptoms of any serious medical condition not yet indicated on this form?*

YESNO
29. Symptoms of a serious illness in last 5 years.*
29. Condition/Diagnosis*
29. Date of Onset*

MonthDayYear
Date
29. Last treated Date*

MonthDayYear
Date
29. Treatment/Drug*
29. Still Taking?*

YESNO
29. Degree of Recovery*
Add additional family members?*

YESNO
29a. Symptoms of a serious illness in last 5 years.*
29a. Condition/Diagnosis*
29a. Date of Onset*

MonthDayYear
Date
29a. Last treated Date*

MonthDayYear
Date
29a. Treatment/Drug*
29a. Still Taking?*

YESNO
29a. Degree of Recovery*
30. Is anyone pregnant?*

YESNO
a) Pregnancy*
b) Due date*

MonthDayYear
Date
c) Is this a high-risk pregnancy, any complications or bleeding?*

YESNO
30c. Pregnancy: High Risk / Complications *
30c. Condition/Diagnosis*
30c. Date of Onset*

MonthDayYear
Date
30c. Last treated Date*

MonthDayYear
Date
30c. Treatment/Drug*
30c. Still Taking?*

YESNO
30c. Degree of Recovery*
d) Previous c-section or pre-term birth?*

YESNO
30d. Pregnancy: Previous C-section or preterm birth*
30d. Condition/Diagnosis*
30d. Date of Onset*

MonthDayYear
Date
30d. Last treated Date*

MonthDayYear
Date
30d. Treatment/Drug*
30d. Still Taking?*

YESNO
30d. Degree of Recovery*
e) Are multiple births expected?*

YESNO
30e. Expected multiple birth:*

TwinsTripletsOther
PHI Disclosure

By signing this application, I understand the following: That if any information submitted on this form constitutes fraud or there is an intentional misrepresentation of the material fact, the plan may rescind healthcare coverage. In any such case, I understand that the plan will return any contributions that have previously been paid as to the rescinded coverage, minus administrative expenses and claims paid. I certify that the statements are true and correct to the best of my knowledge. I understand that this form is used for information purposes only and does not bind coverage. I understand the AAHP gathers this information for statistical and actuarial uses only and it will not be used in connection with decisions or actions regarding employment. That if I am a resident in Michigan, I do not have to provide information regarding height or weight, and that this in compliance with requirements for GINA. That I have read the Client Privacy Notification provided to me in this application. That as a prospective member, I have the right to request restrictions on how my protected health information is used, and that the AAHP is not required by law to grant this request, but if the request is granted, the AAHP is bound by this agreement. I also understand that I have the right to revoke this consent in writing, except to the extent the AAHP Program has already used or disclosed the protected health information in reliance upon my consent. I further understand that the AAHP program will notify me the member of any health or enrollment related changes that occur after signing this form, up to the effective date of coverage

Client Privacy Notification

Thank you for completing the requested information. Any information, including non-public personal health information, such as name, address and social security number, including detailed protected health information provided will be used for the sole purpose of providing a risk assessment to the health plan that will provide a health care benefit quote to your employer. The AAHP's actuary is a legally contracted underwriter acting as a Business Associate to the AAHP Program and is subject to certain provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. The AAHP's actuary and underwriter will not sell, license, transmit or disclose this information outside of their offices except as: a) necessary for them to provide the services on behalf of the health plan, b) expressly authorized by you, c) necessary for backup documentation purposes, or d) required by law.
Please verify that you are human*
Date*

MonthDayYear
Date
Signature*

Clear
PO Box 450978 | Westlake, OH 44145 | 877-585-8480
Should be Empty:

PHQ: Personal Health Questionnaire

I. Demographic Build & Tobacco Use

II. Medical Conditions & Treatments