LTC Health History Questionnaire

HEALTH HISTORY QUESTIONNAIRE
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The first step in long-term care expense planning is determining insurability. Long-term care insurance is medically underwritten. Health history will determine carrier, product and ultimately the cost of a policy. Please complete this questionnaire providing as much detail as possible.
PERSONAL INFORMATION:
First Name*
Last Name*
Gender*
Marital Status:*
DOB: *

MonthDayYear
Date
Actual Age
Height*
Weight*
Do you work full time?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Work Phone
E-mail*
example@example.com
MEDICAL INFORMATION:
Do you use mechanical devices such as a wheelchair, walker, quad cane, crutches, hospital bed, dialysis machine, oxygen, CPAP or stair lift?*
Are you cognitively impaired or do you currently need or receive help in doing any of the following activities of daily living (ADLs): bathing, eating, dressing, toileting, transferring or maintaining continence?*
Have you had another long-term care insurance policy in force during the last 12 months?*
If yes, please provide name of the insurance company?*
Are you currently covered by Medicaid (not Medicare)?*
Are you currently receiving disability payments including Worker’s Compensation or Social Security disability Insurance, short-term or long-term disability benefits?*
Do you intend to replace any of your health care insurance with the coverage applied for?*
Have you had a gain or loss of more than 10 pounds in the last 12 months?*
Have you used tobacco products (smoked, chewed, or used nicotine delivery system) including pipes and cigars in the last five years?*
If yes to tobacco, please explain how long, how often, product type:*
Have you been advised to limit, reduce, discontinue or seek counseling for the use of alcohol or drugs?*
Have you been hospitalized in the past five years?*
If yes to hospitalization, please explain:*
Has any surgery or any diagnostic testing been recommended but not performed?*
If yes to testing, please explain:*
Have you had any surgeries or hospital stays in the last 10 Years:*
If yes to surgeries, please list the surgery and year it was performed.
Have you ever been declined for long-term care insurance or life insurance?*
If yes to being declined, with which company, when and why?*
Please list any medications, date first prescribed, reason prescribed and dosage: *
When was your last physical exam?*
What was your last blood pressure reading?*
On what date was your last blood pressure reading?*
What is your total cholesterol?*
What is your cholesterol ratio?*
What were your last T-scores (bone density)?*
When was the last reading taken?*
Have either of your parents been diagnosed with dementia?*
Have both of your parents diagnosed with dementia?*
Please list any additional health information related to blood pressure, cholesterol and osteoporosis.
Please list any additional health information related to cancer.
Please list any additional health information related to diabetes.
Any additional comments?
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HEALTH HISTORY QUESTIONNAIRE

PERSONAL INFORMATION:

MEDICAL INFORMATION: