Form

PHQ Form: Personal Health Questionnaire
Name*

First NameMiddle NameLast Name
Company Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requested START DATE for Coverage*

MonthDayYear
Date
Household Size*
Enter # of Household Residents
25K - 50K100K - 150K50K - 75K150K - 200K75K - 100K200K+
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*

MonthDayYear
Date
Gender at Birth*
Height*
FEET / INCHES
Weight*
POUNDS
YESNO
YESNO
Name (Spouse)*

First NameLast Name
Date of Birth (Spouse)*

MonthDayYear
Date
Gender at Birth (Spouse)*
Height (Spouse)*
FEET / INCHES
Weight (Spouse)*
POUNDS
YESNO
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
YESNO
1. Cancer*
Name of Individual
1. Date of Onset*

MonthDayYear
Date
1. Condition/Diagnosis*
Stage 1Stage 2Stage 3Stage 4 or Higher
1. Last Treated Date*

MonthDayYear
Date
1. Treatment/Drug*
YESNO
1. Degree of Recovery*
YESNO
1a. Cancer*
Name of Individual
1a. Date of Onset*

MonthDayYear
Date
1a. Condition/Diagnosis*
Stage 1Stage 2Stage 3Stage 4 or Higher
1a. Last Treated Date*

MonthDayYear
Date
1a. Treatment Drug*
YESNO
1a. Degree of Recovery*
YESNO
2. Cardiac or Heart Disease*
Name of Individual
2. Date of Onset*

MonthDayYear
Date
2. Condition/Diagnosis*
Heart AttackBypass Surgery or Angioplasty on Single VesselBypass on Multiple VesselsOther
2. Last Treated Date*

MonthDayYear
Date
2. Treatment Drug*
YESNO
2. Degree of Recovery*
YESNO
2a. Cardiac or Heart Disease*
Name of Individual
2a. Date of Onset.*

MonthDayYear
Date
2a. Condition/Diagnosis*
Heart AttackBypass Surgery or Angioplasty on Single VesselBypass on Multiple VesselsOther
2a. Last Treated Date*

MonthDayYear
Date
2a. Treatment Drug*
YESNO
2a. Degree of Recovery*
YESNO
3. Diabetes*
Name of Individual
3. Date of Onset*

MonthDayYear
Date
3. List the 3 MOST RECENT HbA1c/ Fasting Blood Sugar Levels*
1) Blood Sugar Label 2) Blood Sugar Level 3) Blood Sugar Level
3. Condition/Diagnosis*
3. Last Treated Date*

MonthDayYear
Date
3. Treatment/Drug*
YESNO
3. Degree of Recovery*
YESNO
3a. Diabetes*
Name of Individual
3a. Date of Onset*

MonthDayYear
Date
3a. List the 3 MOST RECENT HbA1c/ Fasting Blood Sugar Levels*
1) Blood Sugar Label 2) Blood Sugar Level 3) Blood Sugar Level
3a. Condition/Diagnosis*
3a. Last Treated Date*

MonthDayYear
Date
3a. Treatment/Drug*
YESNO
3a. Degree of Recovery*
YESNO
4. High Cholesterol*
Name of Individual
4. Date of Onset*

MonthDayYear
Date
4. List the 3 MOST RECENT Cholesterol Readings:*
1) Cholesterol 2) Cholesterol 3) Cholesterol
4. Condition/Diagnosis*
4. Last Treated Date *

MonthDayYear
Date
4. Treatment/Drug*
YESNO
4. Degree of Recovery*
YESNO
4a. High Cholesterol*
Name of Individual
4a. Date of Onset*

MonthDayYear
Date
4a. List the 3 MOST RECENT Cholesterol Readings:*
1) Cholesterol 2) Cholesterol 3) Cholesterol
4a. Condition/Diagnosis*
4a. Last Treated Date *

MonthDayYear
Date
4a. Treatment/Drug*
YESNO
4a. Degree of Recovery*
YESNO
5. High Blood Pressure*
Name of Individual
5. Date of Onset*

MonthDayYear
Date
5. List the 3 MOST RECENT High Blood Pressure Readings:*
1) HBP 2) HBP 3) HBP
5. Condition/Diagnosis*
5. Last Treated Date *

MonthDayYear
Date
5. Treatment/Drug*
YESNO
5. Degree of Recovery*
YESNO
5a. High Blood Pressure*
Name of Individual
5a. Date of Onset*

MonthDayYear
Date
5a. List the 3 MOST RECENT High Blood Pressure Readings:*
1) HBP 2) HBP 3) HBP
5a. Condition/Diagnosis*
5a. Last Treated Date *

MonthDayYear
Date
5a. Treatment/Drug*
YESNO
5a. Degree of Recovery*
YESNO
6. Arthritis*
Name of Individual
6. Condition/Diagnosis*
6. Date of Onset*

MonthDayYear
Date
6. Last Treated Date*

MonthDayYear
Date
6. Treatment/Drug*
YESNO
6. Degree of Recovery*
YESNO
6a. Arthritis*
Name of Individual
6a. Condition/Diagnosis*
6a. Date of Onset*

MonthDayYear
Date
6a. Last Treated Date*

MonthDayYear
Date
6a. Treatment/Drug*
YESNO
6a. Degree of Recovery*
YESNO
7. Arthritis*
Name of Individual
7. Condition/Diagnosis*
7. Date of Onset*

MonthDayYear
Date
7. Last Treated Date*

MonthDayYear
Date
7. Treatment/Drug*
YESNO
7. Degree of Recovery*
YESNO
7a. Arthritis*
Name of Individual
7a. Condition/Diagnosis*
7a. Date of Onset*

MonthDayYear
Date
7a. Last Treated Date*

MonthDayYear
Date
7a. Treatment/Drug*
YESNO
7a. Degree of Recovery*
YESNO
8. Back Disorder*
Name of Individual
8. Condition/Diagnosis*
8. Date of Onset*

MonthDayYear
Date
8. Last Treated Date*

MonthDayYear
Date
8. Treatment/Drug*
YESNO
8. Degree of Recovery*
YESNO
8a. Back Disorder*
Name of Individual
8a. Condition/Diagnosis*
8a. Date of Onset*

MonthDayYear
Date
8a. Last Treated Date*

MonthDayYear
Date
8a. Treatment/Drug*
YESNO
8a. Degree of Recovery*
YESNO
9. Benign Growth*
Name of Individual
9. Condition/Diagnosis*
9. Date of Onset*

MonthDayYear
Date
9. Last Treated Date*

MonthDayYear
Date
9. Treatment/Drug*
YESNO
9. Degree of Recovery*
YESNO
9a. Benign Growth*
Name of Individual
9a. Condition/Diagnosis*
9a. Date of Onset*

MonthDayYear
Date
9a. Last Treated Date*

MonthDayYear
Date
9a. Treatment/Drug*
YESNO
9a. Degree of Recovery*
YESNO
10. Bowel*
Name of Individual
10. Condition/Diagnosis*
10. Date of Onset*

MonthDayYear
Date
10. Last Treated Date*

MonthDayYear
Date
10. Treatment/Drug*
YESNO
10. Degree of Recovery*
YESNO
10a. Bowel*
Name of Individual
10a. Condition/Diagnosis*
10a. Date of Onset*

MonthDayYear
Date
10a. Last Treated Date*

MonthDayYear
Date
10a. Treatment/Drug*
YESNO
10a. Degree of Recovery*
YESNO
11. Circular System Disease*
Name of Individual
11. Condition/Diagnosis*
11. Date of Onset*

MonthDayYear
Date
11. Last Treated Date*

MonthDayYear
Date
11. Treatment/Drug*
YESNO
11. Degree of Recovery*
YESNO
11a. Circular System Disease*
Name of Individual
11a. Condition/Diagnosis*
11a. Date of Onset*

MonthDayYear
Date
11a. Last Treated Date*

MonthDayYear
Date
11a. Treatment/Drug*
YESNO
11a. Degree of Recovery*
YESNO
12. Immunodeficiency*
Name of Individual
12. Condition/Diagnosis*
12. Date of Onset*

MonthDayYear
Date
12. Last Treated Date*

MonthDayYear
Date
12. Treatment/Drug*
YESNO
12. Degree of Recovery*
YESNO
12a. Immunodeficiency*
Name of Individual
12a. Condition/Diagnosis*
12a. Date of Onset*

MonthDayYear
Date
12a. Last Treated Date*

MonthDayYear
Date
12a. Treatment/Drug*
YESNO
12a. Degree of Recovery*
YESNO
13. Kidney*
Name of Individual
13. Condition/Diagnosis*
13. Date of Onset*

MonthDayYear
Date
13. Last Treated Date*

MonthDayYear
Date
13. Treatment/Drug*
YESNO
13. Degree of Recovery*
YESNO
13a. Kidney*
Name of Individual
13a. Condition/Diagnosis*
13a. Date of Onset*

MonthDayYear
Date
13a. Last Treated Date*

MonthDayYear
Date
13a. Treatment/Drug*
YESNO
13a. Degree of Recovery*
YESNO
14. Liver Disease*
Name of Individual
14. Condition/Diagnosis*
14. Date of Onset*

MonthDayYear
Date
14. Last Treated Date*

MonthDayYear
Date
14. Treatment/Drug*
YESNO
14. Degree of Recovery*
YESNO
14a. Liver Disease*
Name of Individual
14a. Condition/Diagnosis*
14a. Date of Onset*

MonthDayYear
Date
14a. Last Treated Date*

MonthDayYear
Date
14a. Treatment/Drug*
YESNO
14a. Degree of Recovery*
YESNO
15. Mental Illness*
Name of Individual
15. Condition/Diagnosis*
15. Date of Onset*

MonthDayYear
Date
15. Last Treated Date*

MonthDayYear
Date
15. Treatment/Drug*
YESNO
15. Degree of Recovery*
YESNO
15a. Mental Illness*
Name of Individual
15a. Condition/Diagnosis*
15a. Date of Onset*

MonthDayYear
Date
15a. Last Treated Date*

MonthDayYear
Date
15a. Treatment/Drug*
YESNO
15a. Degree of Recovery*
YESNO
16. Counseling*
Name of Individual
16. Condition/Diagnosis*
16. Date of Onset*

MonthDayYear
Date
16. Last Treated Date*

MonthDayYear
Date
16. Treatment/Drug*
YESNO
16. Degree of Recovery*
YESNO
16a. Counseling*
Name of Individual
16a. Condition/Diagnosis*
16a. Date of Onset*

MonthDayYear
Date
16a. Last Treated Date*

MonthDayYear
Date
16a. Treatment/Drug*
YESNO
16a. Degree of Recovery*
YESNO
17. Muscular Disorder*
Name of Individual
17. Condition/Diagnosis*
17. Date of Onset*

MonthDayYear
Date
17. Last Treated Date*

MonthDayYear
Date
17. Treatment/Drug*
YESNO
17. Degree of Recovery*
YESNO
17a. Muscular Disorder*
Name of Individual
17a. Condition/Diagnosis*
17a. Date of Onset*

MonthDayYear
Date
17a. Last Treated Date*

MonthDayYear
Date
17a. Treatment/Drug*
YESNO
17a. Degree of Recovery*
YESNO
18. Respiratory*
Name of Individual
18. Condition/Diagnosis*
18. Date of Onset*

MonthDayYear
Date
18. Last Treated Date*

MonthDayYear
Date
18. Treatment/Drug*
YESNO
18. Degree of Recovery*
YESNO
18a. Respiratory*
Name of Individual
18a. Condition/Diagnosis*
18a. Date of Onset*

MonthDayYear
Date
18a. Last Treated Date*

MonthDayYear
Date
18a. Treatment/Drug*
YESNO
18a. Degree of Recovery*
YESNO
19. Stomach*
Name of Individual
19. Condition/Diagnosis*
19. Date of Onset*

MonthDayYear
Date
19. Last Treated Date*

MonthDayYear
Date
19. Treatment/Drug*
YESNO
19. Degree of Recovery*
YESNO
19a. Stomach*
Name of Individual
19a. Condition/Diagnosis*
19a. Date of Onset*

MonthDayYear
Date
19a. Last Treated Date*

MonthDayYear
Date
19a. Treatment/Drug*
YESNO
19a. Degree of Recovery*
YESNO
20. Substance Dependency*
Name of Individual
20. Condition/Diagnosis*
20. Date of Onset*

MonthDayYear
Date
20. Last Treated Date*

MonthDayYear
Date
20. Treatment/Drug*
YESNO
20. Degree of Recovery*
YESNO
20a. Substance Dependency*
Name of Individual
20a. Condition/Diagnosis*
20a. Date of Onset*

MonthDayYear
Date
20a. Last Treated Date*

MonthDayYear
Date
20a. Treatment/Drug*
YESNO
20a. Degree of Recovery*
YESNO
21. Transplants*
Name of Individual
21. List of Organs*
21. Condition/Diagnosis*
21. Date of Onset*

MonthDayYear
Date
21. Last Treated Date*

MonthDayYear
Date
21. Treatment/Drug*
YESNO
21. Degree of Recovery*
YESNO
21a. Transplants*
Name of Individual
21a. List of Organs*
21a. Condition/Diagnosis*
21a. Date of Onset*

MonthDayYear
Date
21a. Last Treated Date*

MonthDayYear
Date
21a. Treatment/Drug*
YESNO
21a. Degree of Recovery*
YESNO
22. Prescription Medication*
Name of Individual
22. Prescription Drug (1)*
YESNO
Condition/Diagnosis: Reasoning for Medication (1) *
22. Prescription Drug (2)*
YESNO
Condition/Diagnosis: Reasoning for Medication (2)*
22. Prescription Drug (3)*
YESNO
Condition/Diagnosis: Reasoning for Medication (3)*
22. Prescription Drug (4)*
YESNO
Condition/Diagnosis: Reasoning for Medication (4) *
22. Prescription Drug (5)*
YESNO
Condition/Diagnosis: Reasoning for Medication (5)*
YESNO
22a. Prescription Medication*
Name of Individual
22a. Prescription Drug (1)*
YESNO
Condition/Diagnosis: Reasoning for Medication (1)*
22a. Prescription Drug (2)*
YESNO
Condition/Diagnosis: Reasoning for Medication (2)*
22a. Prescription Drug (3)*
YESNO
Condition/Diagnosis: Reasoning for Medication (3)*
22a. Prescription Drug (4)*
YESNO
Condition/Diagnosis: Reasoning for Medication (4)*
22a. Prescription Drug (5)*
YESNO
Condition/Diagnosis: Reasoning for Medication (5)*
TreatmentHospitalizationSurgeryNO
23a. Treatment for Serious Illness in the LAST 5 Years*
Name of Individual
23a. Condition/Diagnosis*
23a. Date of Onset*

MonthDayYear
Date
23a. Last Treated Date*

MonthDayYear
Date
23a. Treatment/Drug*
YESNO
23a. Degree of Recovery*
YESNO
23aa. Treatment for Serious Illness in the LAST 5 Years*
Name of Individual
23aa. Condition/Diagnosis*
23aa. Date of Onset*

MonthDayYear
Date
23aa. Last Treated Date*

MonthDayYear
Date
23aa. Treatment/Drug*
YESNO
23aa. Degree of Recovery*
23b. Hospitalization for Serious Illness in the LAST 5 Years*
Name of Individual
23b. Condition/Diagnosis*
23b. Date of Onset*

MonthDayYear
Date
23b. Last Treated Date*

MonthDayYear
Date
23b. Treatment/Drug*
YESNO
23b. Degree of Recovery*
YESNO
23bb. Hospitalization for Serious Illness in the LAST 5 Years*
Name of Individual
23bb. Condition/Diagnosis*
23bb. Date of Onset*

MonthDayYear
Date
23bb. Last Treated Date*

MonthDayYear
Date
23bb. Treatment/Drug*
YESNO
23bb. Degree of Recovery*
23c. Surgery for Serious Illness in the LAST 5 Years*
Name of Individual
23c. Condition/Diagnosis*
23c. Date of Onset*

MonthDayYear
Date
23c. Last Treated Date*

MonthDayYear
Date
23c. Treatment/Drug*
YESNO
23c. Degree of Recovery*
YESNO
23cc. Surgery for Serious Illness in the LAST 5 Years*
Name of Individual
23cc. Condition/Diagnosis*
23cc. Date of Onset*

MonthDayYear
Date
23cc. Last Treated Date*

MonthDayYear
Date
23cc. Treatment/Drug*
YESNO
23cc. Degree of Recovery*
YESNO
24. Currently Hospitalized or confined in a treatment facility*
Name of Individual
24. Condition/Diagnosis*
24. Date of Onset*

MonthDayYear
Date
24. Last Treated Date*

MonthDayYear
Date
24. Treatment/Drug*
YESNO
24. Degree of Recovery*
YESNO
24a. Currently Hospitalized or confined in a treatment facility*
Name of Individual
24a. Condition/Diagnosis*
24a. Date of Onset*

MonthDayYear
Date
24a. Last Treated Date*

MonthDayYear
Date
24a. Treatment/Drug*
YESNO
24a. Degree of Recovery*
YESNO
25. Currently Hospitalized or confined in a treatment facility*
Name of Individual
25. Condition/Diagnosis*
25. Date of Onset*

MonthDayYear
Date
25. Last Treated Date*

MonthDayYear
Date
25. Treatment/Drug*
YESNO
25. Degree of Recovery*
YESNO
25a. Currently Hospitalized or confined in a treatment facility*
Name of Individual
25a. Condition/Diagnosis*
25a. Date of Onset*

MonthDayYear
Date
25a. Last Treated Date*

MonthDayYear
Date
25a. Treatment/Drug*
YESNO
25a. Degree of Recovery*
YESNO
26. Pending Treatment (Medical or Diagnostic)*
Name of Individual
26. Condition/Diagnosis*
26. Date of Onset*

MonthDayYear
Date
26. Last Treated Date*

MonthDayYear
Date
26. Treatment/Drug*
YESNO
26. Degree of Recovery*
YESNO
26a. Pending Treatment (Medical or Diagnostic)*
Name of Individual
26a. Condition/Diagnosis*
26a. Date of Onset*

MonthDayYear
Date
26a. Last Treated Date*

MonthDayYear
Date
26a. Treatment/Drug*
YESNO
26a. Degree of Recovery*
YESNO
27. Pending Hospitalization*
Name of Individual
27. Condition/Diagnosis*
27. Date of Onset*

MonthDayYear
Date
27. Last Treated Date*

MonthDayYear
Date
27. Treatment/Drug*
YESNO
27. Degree of Recovery*
YESNO
27a. Pending Hospitalization*
Name of Individual
27a. Condition/Diagnosis*
27a. Date of Onset*

MonthDayYear
Date
27a. Last Treated Date*

MonthDayYear
Date
27a. Treatment/Drug*
YESNO
27a. Degree of Recovery*
YESNO
28. Pending Hospitalization*
Name of Individual
28. Condition/Diagnosis*
28. Date of Onset*

MonthDayYear
Date
28. Last Treated Date*

MonthDayYear
Date
28. Treatment/Drug*
YESNO
28. Degree of Recovery*
YESNO
28a. Pending Hospitalization*
Name of Individual
28a. Condition/Diagnosis*
28a. Date of Onset*

MonthDayYear
Date
28a. Last Treated Date*

MonthDayYear
Date
28a. Treatment/Drug*
YESNO
28a. Degree of Recovery*
YESNO
29. Symptoms of a Serious Illness in the LAST 5 YEARS*
Name of Individual
29. Condition/Diagnosis*
29. Date of Onset*

MonthDayYear
Date
29. Last Treated Date*

MonthDayYear
Date
29. Treatment/Drug*
YESNO
29. Degree of Recovery*
YESNO
29a. Symptoms of a Serious Illness in the LAST 5 YEARS*
Name of Individual
29a. Condition/Diagnosis*
29a. Date of Onset*

MonthDayYear
Date
29a. Last Treated Date*

MonthDayYear
Date
29a. Treatment/Drug*
YESNO
29a. Degree of Recovery*
YESNO
A) Pregnancy*
Name of Individual
B) Due Date*

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

MonthDayYear
Date
30c. Last Treated Date*

MonthDayYear
Date
30c. Treatment/Drug*
YESNO
30c. Degree of Recovery*
YESNO
30d. Pregnancy: Previous C-Section or Pre-Term Birth*
Name of Individual
30d. Condition/Diagnosis*
30d. Date of Onset*

MonthDayYear
Date
30d. Last Treated Date*

MonthDayYear
Date
30d. Treatment/Drug*
YESNO
30d. Degree of Recovery*
YESNO
TwinsTripletsOther
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*

MonthDayYear
Date
Signature*

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PHQ Form: Personal Health Questionnaire