Client Intake and Medical History Form

Client Intake and Medical History Form

w/ Independent Broker Danisha Matta-Field
Please fill out each section to the best of your ability

(This form is encrypted and the information provided is only available to me - You will be contacted by me personally - I am an independent business, not a call center.)
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Height and Weight
ex: 5'1" - 125 lbs (cm - kilos acceptable)
Gender
Spouse

Birthday mm/dd/yyFirst NameLast NameGender
Dependent
Interested In
Dental
Vision
How do you prefer to be contacted?

What is your availability? I'll reach out according to your selections - PS: Don't worry!! If I don't get a hold of you, I'll only reach again on the next selected day and time frame, I'm an independent business, not a call center :)

Rows	Sun	Mon	Tue	Wed	Thur	Fri	Sat
9AM - 11AM
11AM - 1PM
1PM - 4PM
5PM - 8PM

Do you use tobacco/vapes?
Do you currently have any health coverage?
If you currently have coverage please fill out the following to the best of your knowledge (If you had coverage in the past, please fill this portion out with that coverage in mind)
Annual Income
Monthly Budget for All Coverage Needs
(Dental, Vision, Health and/or Life Insurance)
Are you or an applicant taking medications?
How often do you go to the doctor?
List your medications
Is any applicant currently pregnant or expecting?
Please List Your Doctors, PCP, Specialists, Dentist, etc.
Does any applicant own or lease a motorcycle?
Has any adult applicant had any citations for DUI/DWI or more than 1 moving violation including speeding ticket(s) within the past 2 years?

Medical History

Rows	Parents	Self	Spouse	Dependent	Dependent	Grandparents	Other Family
Alcohol/Drug Abuse
Asthma
Emphysema (COPD)
Depression / Anxiety
Bipolar / Suicidal
Diabetes
Early Death
Heart Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Stroke
Thyroid Disease
Migraines
Cancer
Other not mentioned

Please Indicate further health history - (Specific type of diabetes or cancer - unlisted illness, disease or syndrome, reason for hospital stay)
Within the last 5 years, has any applicant received medical treatment or has medication been prescribed or recommended for High Blood Pressure, High Cholesterol, Anxiety, or Depression
In the past 5 years has any applicant been home-bound or incapacitated or incapable of self-support due to a medical condition?
Has any applicant been under the care of a doctor currently or in the past 5 years for Autoimmune or blood disease i.e., Lupus MS, Anemia, AIDS, HIV, Hemophilia, IBS, Crohn's?
Has any applicant been under the care of a doctor - currently or in the past 5 years, for Organ Failure or Organ Transplant for Kidney, Liver, Lung, Heart and or any form of organ support i.e., dialysis?
Is any applicant currently being treated for a condition you have been hospitalized for in the past 5 years?
Has any applicant been under the care of a doctor currently or in the past 5 years for a previous major surgery? Or have an upcoming planned surgery?
Please indicate the major surgeries that you had or plan on (if any)
Should be Empty:

Client Intake and Medical History Form

Please fill out each section to the best of your ability