• Health Questionnaire

    *All Sections Are Required*
  • Gender*
  • Date of Birth*
     - -
  • Do you reside in Mexico or are you planning on moving to Mexico in the near future?*
  • When do you plan on relocating?*
     - -
  • What is or will your future Mexican immigration status be when you move to Mexico?*
  • 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)?*
  • Are you looking for health coverage in the US & Mexico?*
  • PA: Medical Info - Taking any medications?*
  • PA: Medical Info - Any surgeries &/or medical treatment?*
  • PA: Use tobacco products?*
  • PA: Which tobacco products?
  • + Spouse / Domestic Partner - Do you want to add a Spouse / Domestic Partner?*
    • Spouse / Domestic Partner Information 
    • + Spouse - Date of Birth*
       - -
    • + Spouse Medical - Taking any medications?*
    • + Spouse Medical - Any surgeries &/or medical treatment?*
    • + Spouse: Use tobacco products?*
    • + Spouse: Which tobacco products?
    • Children's Information 
    • + Child #1 - Date of Birth*
       - -
    • + Child #1 - Medical: Is this child taking medications?*
    • + Child #1 Medical - Any surgeries or medical treatment?*
    • + Child #1: Use tobacco products?*
    • + Child #1: Which tobacco products?
    • + Child #2 - Date of Birth*
       - -
    • + Child #2 - Medical: Is this child taking medications?*
    • + Child #2 - Any surgeries or medical treatment?*
    • + Child #2: Use tobacco products?*
    • + Child #2: Which tobacco products?
    • + Child #3 - Date of Birth*
       - -
    • + Child #3 - Medical: Is this child taking medications?*
    • + Child #3 - Any surgeries or medical treatment?*
    • + Child #3: Use tobacco products?*
    • + Child #3: Which tobacco products?
    • + Child #4 - Date of Birth*
       - -
    • + Child #4 - Medical: Is this child taking medications?*
    • + Child #4 - Any surgeries or medical treatment?*
    • + Child #4: Use tobacco products?*
    • + Child #4: Which tobacco products?
    • End Children's Information 
  • Should be Empty: