• PHQ Form: Personal Health Questionnaire

    PHQ Form: Personal Health Questionnaire

  • Format: (000) 000-0000.
  • Requested START DATE for Coverage*
     - -
  • Pharmacy Assistance Program Income Qualification: Please INPUT the Range of Your PRE-TAX Household Yearly Income.*

  • l. 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.
  • Date of Birth*
     - -
  • Are you ADDING a Spouse/ Domestic Partner?*
  • Are you ADDING Child/Children?*
  • Date of Birth (Spouse)*
     - -
  • Tobacco Use in the Last Year?*

  • ll. 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 of the following questions.
    Please complete ADDITIONAL DETAIL SECTION for ALL 'YES' answers

  • 1. CANCER*
  • 1. Date of Onset*
     - -
  • 1. Check ONE*
  • 1. Last Treated Date*
     - -
  • 1. Still Taking?*
  • ADD Additional Family Members?*
  • 1a. Date of Onset*
     - -
  • 1a. Check ONE*
  • 1a. Last Treated Date*
     - -
  • 1a. Still Taking?*
  • 2. CARDIAC or HEART DISEASE*
  • 2. Date of Onset*
     - -
  • Check ALL that Apply:*
  • 2. Last Treated Date*
     - -
  • 2. Still Taking?*
  • ADD Additional Family Members?*
  • 2a. Date of Onset.*
     - -
  • 2a. Check ALL that Apply:*
  • 2a. Last Treated Date*
     - -
  • 2a. Still Taking?*
  • 3. DIABETES*
  • 3. Date of Onset*
     - -
  • 3. Last Treated Date*
     - -
  • 3. Still Taking?*
  • ADD Additional Family Members?*
  • 3a. Date of Onset*
     - -
  • 3a. Last Treated Date*
     - -
  • 3a. Still Taking?*
  • 4. HIGH CHOLESTEROL*
  • 4. Date of Onset*
     - -
  • 4. Last Treated Date *
     - -
  • 4. Still Taking?*
  • ADD Additional Family Members?*
  • 4a. Date of Onset*
     - -
  • 4a. Last Treated Date *
     - -
  • 4a. Still Taking?*
  • 5. HIGH BLOOD PRESSURE*
  • 5. Date of Onset*
     - -
  • 5. Last Treated Date *
     - -
  • 5. Still Taking?*
  • ADD Additional Family Members?*
  • 5a. Date of Onset*
     - -
  • 5a. Last Treated Date *
     - -
  • 5a. Still Taking?*
  • 6. ARTHRITIS (i.e. Rheumatoid, Osteo, Psoriatic, Gout)*
  • 6. Date of Onset*
     - -
  • 6. Last Treated Date*
     - -
  • 6. Still Taking?*
  • ADD Additional Family Members?*
  • 6a. Date of Onset*
     - -
  • 6a. Last Treated Date*
     - -
  • 6a. Still Taking?*
  • 7. AUTOIMMUNE DISEASE (i.e. Lupus, MS, Anemia)*
  • 7. Date of Onset*
     - -
  • 7. Last Treated Date*
     - -
  • 7. Still Taking?*
  • ADD Additional Family Members?*
  • 7a. Date of Onset*
     - -
  • 7a. Last Treated Date*
     - -
  • 7a. Still Taking?*
  • 8. BACK DISORDER (i.e. Degenerative Disk Disease, Herniated Disk, Spinal Fusion, Spondylitis, Strain)*
  • 8. Date of Onset*
     - -
  • 8. Last Treated Date*
     - -
  • 8. Still Taking?*
  • ADD Additional Family Members?*
  • 8a. Date of Onset*
     - -
  • 8a. Last Treated Date*
     - -
  • 8a. Still Taking?*
  • 9. BENIGN GROWTH (i.e. Tumor, Cyst)*
  • 9. Date of Onset*
     - -
  • 9. Last Treated Date*
     - -
  • 9. Still Taking?*
  • ADD Additional Family Members?*
  • 9a. Date of Onset*
     - -
  • 9a. Last Treated Date*
     - -
  • 9a. Still Taking?*
  • 10. BOWEL (i.e. Irritable Bowel IBS, Crohn's ileitis)*
  • 10. Date of Onset*
     - -
  • 10. Last Treated Date*
     - -
  • 10. Still Taking?*
  • ADD Additional Family Members?*
  • 10a. Date of Onset*
     - -
  • 10a. Last Treated Date*
     - -
  • 10a. Still Taking?*
  • 11. CIRCULATORY SYSTEM DISEASE (i.e. Stroke, Arterial/ Vascular Diseases)*
  • 11. Date of Onset*
     - -
  • 11. Last Treated Date*
     - -
  • 11. Still Taking?*
  • ADD Additional Family Members?*
  • 11a. Date of Onset*
     - -
  • 11a. Last Treated Date*
     - -
  • 11a. Still Taking?*
  • 12. IMMUNODEFICIENCY (i.e. AIDS, HIV+, Hemophilia)*
  • 12. Date of Onset*
     - -
  • 12. Last Treated Date*
     - -
  • 12. Still Taking?*
  • ADD Additional Family Members?*
  • 12a. Date of Onset*
     - -
  • 12a. Last Treated Date*
     - -
  • 12a. Still Taking?*
  • 13. KIDNEY DISORDER (i.e. Nephritis, Renal Failure)*
  • 13. Date of Onset*
     - -
  • 13. Last Treated Date*
     - -
  • 13. Still Taking?*
  • ADD Additional Family Members?*
  • 13a. Date of Onset*
     - -
  • 13a. Last Treated Date*
     - -
  • 13a. Still Taking?*
  • 14. LIVER DISEASE (i.e. Cirrhosis, Hepatitis A, B,C, E)*
  • 14. Date of Onset*
     - -
  • 14. Last Treated Date*
     - -
  • 14. Still Taking?*
  • ADD Additional Family Members?*
  • 14a. Date of Onset*
     - -
  • 14a. Last Treated Date*
     - -
  • 14a. Still Taking?*
  • 15. MENTAL ILLNESS (i.e. Mild or Major Depression, Anxiety, Bipolar Disorder, or Schizophrenia)*
  • 15. Date of Onset*
     - -
  • 15. Last Treated Date*
     - -
  • 15. Still Taking?*
  • ADD Additional Family Members?*
  • 15a. Date of Onset*
     - -
  • 15a. Last Treated Date*
     - -
  • 15a. Still Taking?*
  • 16. COUNSELING (Current or Prior Counseling?)*
  • 16. Date of Onset*
     - -
  • 16. Last Treated Date*
     - -
  • 16. Still Taking?*
  • ADD Additional Family Members?*
  • 16a. Date of Onset*
     - -
  • 16a. Last Treated Date*
     - -
  • 16. Still Taking?*
  • 17. MUSCULAR DISORDER*
  • 17. Date of Onset*
     - -
  • 17. Last Treated Date*
     - -
  • 17. Still Taking?*
  • ADD Additional Family Members?*
  • 17a. Date of Onset*
     - -
  • 17a. Last Treated Date*
     - -
  • 17a. Still Taking?*
  • 18. RESPIRATORY (i.e. Asthma, Allergies, Pneumonia, COPD, Emphysema, Bronchitis)*
  • 18. Date of Onset*
     - -
  • 18. Last Treated Date*
     - -
  • 18. Still Taking?*
  • ADD Additional Family Members?*
  • 18a. Date of Onset*
     - -
  • 18a. Last Treated Date*
     - -
  • 18a. Still Taking?*
  • 19. STOMACH (i.e. Ulcer, Acid Reflux, GERD)*
  • 19. Date of Onset*
     - -
  • 19. Last Treated Date*
     - -
  • 19. Still Taking?*
  • ADD Additional Family Members?*
  • 19a. Date of Onset*
     - -
  • 19a. Last Treated Date*
     - -
  • 19a. Still Taking?*
  • 20. SUBSTANCE DEPENDENCY (i.e. Alcohol, Drug)*
  • 20. Date of Onset*
     - -
  • 20. Last Treated Date*
     - -
  • 20. Still Taking?*
  • ADD Additional Family Members?*
  • 20a. Date of Onset*
     - -
  • 20a. Last Treated Date*
     - -
  • 20a. Still Taking?*
  • 21. TRANSPLANTS*
  • 21. Date of Onset*
     - -
  • 21. Last Treated Date*
     - -
  • 21. Still Taking?*
  • ADD Additional Family Members?*
  • 21a. Date of Onset*
     - -
  • 21a. Last Treated Date*
     - -
  • 21a. Still Taking?*
  • 22. IS ANYONE CURRENTLY TAKING PRESCRIPTION MEDICATION(S)?*
  • 22. Still Taking? (1)*
  • 22. Still Taking? (2)*
  • 22. Still Taking? (3)*
  • 22. Still Taking? (4)*
  • 22. Still Taking? (5)*
  • ADD Additional Family Members?*
  • 22a. Still Taking? (1)*
  • 22a. Still Taking? (2)*
  • 22a. Still Taking? (3)*
  • 22a. Still Taking? (4)*
  • 22a. Still Taking? (5)*
  • 23. HAS ANYONE HAD ANY OF THE FOLLOWING FOR A SERIOUS ILLNESS IN THE PAST 5 YEARS? * Select ALL that Apply *
  • 23a. Date of Onset*
     - -
  • 23a. Last Treated Date*
     - -
  • 23a. Still Taking?*
  • ADD Additional Family Members? (TREATMENT)*
  • 23aa. Date of Onset*
     - -
  • 23aa. Last Treated Date*
     - -
  • 23aa. Still Taking?*
  • 23b. Date of Onset*
     - -
  • 23b. Last Treated Date*
     - -
  • 23b. Still Taking?*
  • ADD Additional Family Members? (HOSPITALIZATION)*
  • 23bb. Date of Onset*
     - -
  • 23bb. Last Treated Date*
     - -
  • 23bb. Still Taking?*
  • 23c. Date of Onset*
     - -
  • 23c. Last Treated Date*
     - -
  • 23c. Still Taking?*
  • ADD Additional Family Members? (SURGERY)*
  • 23cc. Date of Onset*
     - -
  • 23cc. Last Treated Date*
     - -
  • 23cc. Still Taking?*
  • 24. IS ANYONE CURRENTLY HOSPITALIZED OR CONFINED IN A TREATMENT FACILITY?*
  • 24. Date of Onset*
     - -
  • 24. Last Treated Date*
     - -
  • 24. Still Taking?*
  • ADD Additional Family Members?*
  • 24a. Date of Onset*
     - -
  • 24a. Last Treated Date*
     - -
  • 24a. Still Taking?*
  • 25. IS ANYONE CURRENTLY CONFINED AT HOME, INCAPACITATED OR INCAPABLE OF SELF-SUPPORT?*
  • 25. Date of Onset*
     - -
  • 25. Last Treated Date*
     - -
  • 25. Still Taking?*
  • ADD Additional Family Members?*
  • 25a. Date of Onset*
     - -
  • 25a. Last Treated Date*
     - -
  • 25a. Still Taking?*
  • 26. PENDING TREATMENT (Medical Treatment or Diagnostic Testing)*
  • 26. Date of Onset*
     - -
  • 26. Last Treated Date*
     - -
  • 26. Still Taking?*
  • ADD Additional Family Members?*
  • 26a. Date of Onset*
     - -
  • 26a. Last Treated Date*
     - -
  • 26a. Still Taking?*
  • 27. PENDING or UPCOMING HOSPITALIZATION*
  • 27. Date of Onset*
     - -
  • 27. Last Treated Date*
     - -
  • 27. Still Taking?*
  • ADD Additional Family Members?*
  • 27a. Date of Onset*
     - -
  • 27a. Last Treated Date*
     - -
  • 27a. Still Taking?*
  • 28. PENDING or UPCOMING SURGERY*
  • 28. Date of Onset*
     - -
  • 28. Last Treated Date*
     - -
  • 28. Still Taking?*
  • ADD Additional Family Members?*
  • 28a. Date of Onset*
     - -
  • 28a. Last Treated Date*
     - -
  • 28a. Still Taking?*
  • 29. IN THE PAST 5 YEARS, HAS ANYONE ENROLLING HAD SYMPTOMS OF ANY SERIOUS MEDICAL CONDITION NOT YET INDICATED ON THIS FORM?*
  • 29. Date of Onset*
     - -
  • 29. Last Treated Date*
     - -
  • 29. Still Taking?*
  • ADD Additional Family Members?*
  • 29a. Date of Onset*
     - -
  • 29a. Last Treated Date*
     - -
  • 29a. Still Taking?*
  • 30. IS ANYONE PREGNANT?*
  • B) Due Date*
     - -
  • C) Is this a High-Risk Pregnancy, ANY Complications or Bleeding?*
  • 30c. Date of Onset*
     - -
  • 30c. Last Treated Date*
     - -
  • 30c. Still Taking?*
  • D) Previous C-Section or Pre-Term birth?*
  • 30d. Date of Onset*
     - -
  • 30d. Last Treated Date*
     - -
  • 30d. Still Taking?*
  • E) Are Multiple Births Expected?*
  • 30e. Expected Multiple Birth:

  • Premier Shield Benefits

     

    Health Information Collection & Privacy Consent:

    Before we discuss potential health coverage options, we ask that you complete a quick questionnaire about your health history. This helps Premier Shield Benefits (PSB) determine whether certain plans are likely to meet your needs before you go through a carrier’s full underwriting process.

    This questionnaire may collect medical history, diagnoses, medications, treatments, lifestyle information, basic personal identifiers (name, date of birth, contact information) for the purpose of internal review only, to assess potential plan eligibility and suitability.  Premier Shield Benefits will not share information without consent. Your information will not be sent to any insurance carrier, medical provider, or third party without your written authorization. This pre‑qualification is not an offer of coverage nor a guarantee of acceptance.  The information provided will be used to determine eligibility and suitability for plans offered through Premier Shield Benefits.

    Your Information will be stored securely in accordance with all Health Insurance Patient Portability and Accountability Act (HIPAA) requirements regarding safe data handling of Protected Health Information.  This includes measures such as:

    • Stored securely (locked file cabinet for paper, encrypted storage for digital)
    • Access limited to authorized personnel only

    • Retained only as long as necessary for the stated purpose, then securely destroyed

    You may refuse to provide health information; however, this may limit the ability to pre‑qualify you for certain plans.  You also understand that you have the right to revoke this consent in writing, except to the extent Premier Shield Benefits has already used or disclosed the protected health information in reliance upon my consent.  You may request to review, correct, or have your information deleted at any time

    I understand that:

    • The information I provide will be used only for pre‑qualification purposes by Premier Shield Benefits.

    • My information will not be disclosed to any carrier or third party without my written consent.

     

  • Date*
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