This Health Form is HIPAA compliant to protect your personal information.
Name
*
First Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred phone number to contact you.
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred email to contact you.
*
example@example.com
Height
*
Weight
*
Do you have a partner / spouse whith whom you live?
*
Yes
No
Have you had a physical and full panel of blood work in the last 2 years?
*
Yes
No
Were any of your blood labs outside the range of normal?
*
Yes
No
Do You have any medical appointments or tests pending (including those that still need to be scheduled)?
Yes
No
Please list all medications you are currently taking including dosage, reason for taking, and for approximately how long:
Have you have been prescribed medications that you chose not to take or stopped taking without your MD discontinuing the recommendation or order?
*
Yes
No
Do you currently have HIV / AIDS?
*
Yes
No
Do you have ALS, Cirrhosis, Cuystic Fibrosis, Huntington's Chorea, Kidney Disease, Memory Issues, Muscular Dystrophy, Multiple Sclerosis, Parkinson's, Schizophrenia Systemic Lupus?
*
Yes
No
Do you currenty use: Cane, walker, wheelchair, electric scooter, stairlift, hospital bed, nebulizer, or oxygen?
*
Yes
No
Have you been diagnosed with an aneurism?
*
Yes
No
If you have been diagnosed with aneurism, please identify the location and size
Do you currently receive: Beneifts under Disability Income, Medicaid, Social Security Disability, or Workers Compensation?
*
Yes
No
Family History
Have any members of your immediate biological family (father, mother, or sibling) been diagnosed with alzheimer's or another form of Dementia?
*
Yes
No
Past or Present:
Have you had an MRI in the last 5 years?
*
Yes
No
Have you smoked tobacco products or marijuana within the last 24 months or use Marijuana gummies?
*
Yes
No
Had / Have cancer?
*
Yes
No
Had a stroke or TIA?
*
Yes
No
Had any major injuries, falls, mobility issues, or broken bones in the last 2 years?
*
Yes
No
Have Ostoporosis?
*
Yes
No
Have any other chronic illnesses (i.e., Arthritis, Atrial Fibrillation, Chronic Bronchitis, COPD, Diabetes Type I, Diabetes Type II, Emphysema, Hypertension, etc.)?
*
Yes
No
Have Sleep Apnea?
*
Yes
No
Had / Have Cortisone or other kinds of steroid injections in the last 2 years?
*
Yes
No
Had / Have Physical or Occupational Therapy in the last 2 years?
*
Yes
No
Had / Have any substance abuse history with either alcohol or drugs?
*
Yes
No
Had / Have any Depression and/or Anxiety history in the last 5 years?
*
Yes
No
Do you have any residual symptoms from COVID or Lyme Disease?
*
Yes
No
Had / Have any other health issues, surgeries, or treatments not mentioned above in the last 3 years?
*
Yes
No
Financials
Do you own or rent?
*
Own
Rent
Do you have a second property?
*
Yes
No
In what state would you expect to retire (if known)
What other insurances do you presently own?
*
Life Insurance
Disability Insurance
Long Term Care Insurance
Annuities
None of the above
What is the approximate total of your assets not including properties?
*
Please Select
< 100,000
100,000 - 300,000
300,000 - 500,000
500,000 - 750,000
750,000 - 1,000,000
> 1,000,000
Is it important to leave assets to:
*
Children
Other Family
A Charity
Not Applicable
Are you self-employed or own a business?
*
Yes
No
What is your annual income?
*
< $50,000
$51,000 - $100,000
$101,000 - $200,000
$201,000 - $350,000
> $350,000
Do you have an HSA account?
*
Yes
No
On a Scale of 1-10, what is your level of concern that you may spend the premium and never need care?
*
Not Concerned
1
2
3
4
5
6
7
8
9
Very Concerned
10
1 is Not Concerned, 10 is Very Concerned
If you had to take a guess, when do you think yoiu might need care?
*
Before age 80
80 - 85
86 - 90
Older than 90
If you need care, how many years would you want to be sure you could afford to fund?
*
1 - 2 years
3 - 4 years
5 - 6 years
More than 6 years
What do you feel you could afford on an annual premium basis if you saw the value?
*
< $3,000
$3,000 - $4,000
$4,001 - $5,000
$5,001 - $7,000
> $7,000
Other
Have you looked at long term care insurance previously?
*
Yes
No
Are you presently looking at long term care insurance with another source?
*
Yes
No
Have you been declined for long term care insurance in the past?
*
Yes
No
Who referred you to us?
*
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