Clone of Full Cover Health Insurance Questionnaire

Health Questionnaire

*All Sections Are Required*
Name*
Email*
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Passport Issue*
Do you reside in Mexico or are you planning on moving to Mexico in the near future?*

Reside in MexicoWill be moving to Mexico
When do you plan on relocating?*

YearMonthDay
Where in Mexico do you live or will you be living?*
What is or will your future Mexican immigration status be when you move to Mexico?*

TouristTemporary ResidentPermanent ResidentMexican National
Do you currently have a health insurance plan (International health plan, US Marketplace plan, Medicare, Employer-sponsored plan, Mexican health plan or perhaps a Canadian provincial plan)?*

YesNo
Which plan do you currently have?*
What is your current annual payment?*
Are you looking for health coverage in the US & Mexico?*

YesNo
PA: Medical Info - Taking any medications?*

YesNo
PA: Medical Info - Please list all medications and medical conditions associated with them.*
PA: Medical Info - Any surgeries &/or medical treatment?*

YesNo
PA: Medical Info - Please specify surgeries &/or medical treatment?*
PA: Use tobacco products?*

YesNo
PA: Which tobacco products?

CigarettesVapingChewing
+ Spouse / Domestic Partner - Do you want to add a Spouse / Domestic Partner?*

YesNo
- + Spouse - Full Name*
  
  First NameMiddle NameLast Name
- + Spouse - Date of Birth*
  
  MonthDayYear
  Date
- + Spouse - Passport Issue:*
- + Spouse Medical - Taking any medications?*
  
  YesNo
- + Spouse Medical - Please list all medications and medical conditions associated with them.*
- + Spouse Medical - Any surgeries &/or medical treatment?*
  
  YesNo
- + Spouse Medical - Please specify surgeries &/or medical treatment?*
- + Spouse: Use tobacco products?*
  
  YesNo
- + Spouse: Which tobacco products?
  
  CigarettesVapingChewing
- + Children: Do you want to add children?*
- + Child #1 - Full Name*
  
  First NameMiddle NameLast Name
- + Child #1 - Date of Birth*
  
  MonthDayYear
  Date
- + Child #1 - Passport Issue:*
- + Child #1 - Medical: Is this child taking medications?*
  
  YesNo
- + Child #1 Medical - Please list all medications and medical conditions associated with them.*
- + Child #1 Medical - Any surgeries or medical treatment?*
  
  YesNo
- + Child #1 Medical - Please specify surgeries &/or medical treatment?*
- + Child #1: Use tobacco products?*
  
  YesNo
- + Child #1: Which tobacco products?
  
  CigarettesVapingChewing
- + Child #2 - Full Name*
  
  First NameMiddle NameLast Name
- + Child #2 - Date of Birth*
  
  MonthDayYear
  Date
- + Child #2 - Passport Issue:*
- + Child #2 - Medical: Is this child taking medications?*
  
  YesNo
- + Child #2 Medical - Please list all medications and medical conditions associated with them.*
- + Child #2 - Any surgeries or medical treatment?*
  
  YesNo
- + Child #2 Medical - Please specify surgeries &/or medical treatment?*
- + Child #2: Use tobacco products?*
  
  YesNo
- + Child #2: Which tobacco products?
  
  CigarettesVapingChewing
- + Child #3 - Full Name*
  
  First NameMiddle NameLast Name
- + Child #3 - Date of Birth*
  
  MonthDayYear
  Date
- + Child #3 - Passport Issue:*
- + Child #3 - Medical: Is this child taking medications?*
  
  YesNo
- + Child #3 Medical - Please list all medications and medical conditions associated with them.*
- + Child #3 - Any surgeries or medical treatment?*
  
  YesNo
- + Child #3 Medical - Please specify surgeries &/or medical treatment?*
- + Child #3: Use tobacco products?*
  
  YesNo
- + Child #3: Which tobacco products?
  
  CigarettesVapingChewing
- + Child #4 - Full Name*
  
  First NameMiddle NameLast Name
- + Child #4 - Date of Birth*
  
  MonthDayYear
  Date
- + Child #4 - Passport Issue:*
- + Child #4 - Medical: Is this child taking medications?*
  
  YesNo
- + Child #4 Medical - Please list all medications and medical conditions associated with them.*
- + Child #4 - Any surgeries or medical treatment?*
  
  YesNo
- + Child #4 Medical - Please specify surgeries &/or medical treatment?*
- + Child #4: Use tobacco products?*
  
  YesNo
- + Child #4: Which tobacco products?
  
  CigarettesVapingChewing
- Additional Comments
Should be Empty:

Health Questionnaire