LONG-TERM CARE INSURANCE HEALTH GUIDE
CONFIDENTIAL QUESTIONNAIRE. PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE. No Insurance will be issued as a result of the completion of this form
Back
Next
CONFIDENTIAL QUESTIONNAIRE
YOUR INFORMATION
Name:
Date of Birth:
-
Month
-
Day
Year
Date
Address:
Marital Status:
Cell:
Format: (000) 000-0000.
Email:
example@example.com
Height:
Weight:
Gender:
SPOUSE INFORMATION
Spouse's Name:
Date of Birth:
-
Month
-
Day
Year
Date
Address:
Cell:
Format: (000) 000-0000.
Email:
example@example.com
Height:
Weight:
Gender:
FAMILY INFORMATION
How many children do you have?
How many grandchildren do have?
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE
No Insurance will be issued as a result of the completion of this form
PAGE 1
Back
Next
Health History and Medical Information
Do you currently or have you had a long-term care, nursing home and home care, nursing home only, home health care policy or certificate in-force during the last 12 months?
Yes
No
If yes, what type of policy and company?
Have you ever been declined or asked to pay additional premiums for long-term care or life insurance?
Yes
No
If yes, by what company, when and why?
Have you been confined in an assisted living facility in the past?
Yes
No
Have you had any weight loss in the last 12 months?
Yes
No
If yes, how much and why?
Have you ever used tobacco products?
Yes
No
If yes, do you currently use?
Yes
No
If not, when did you last use tobacco products?
Have you been medically advised to enter or been confined to a hospital or health care facility within the last 10 years?
Yes
No
If yes, please provide details and when:
Are you scheduled for, or have you been advised by a physician or health care provider to have additional testing, surgery, or consultation(s) to evaluate health?
Yes
No
If yes, please provide details and when:
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE No Insurance will be issued as a result of the completion of this form
PAGE 2
Back
Next
Do you use any of the following medical equipment?
Medical Equipment
Oxygen
Wheelchair
Crutches
Braces
Walker
Nebulizer
Respirator
Quad Cane
Stair Life
Hospital Bed
Electric Scooter
Bladder Catheter
Kidney Dialysis
Handicap Parking
Implanted Defibrillator
Have you been treated for alcohol or drug abuse?
Yes
No
If yes, please provide details:
Do you need assistance or supervision of another person to help with the following? Bathing, toileting, dressing, eating, walking, medication management, getting in and out of a chair or bed, or control of your bowel or bladder?
Yes
No
Diabetes
Have you been medically diagnosed by a doctor with any type/form of diabetes?
Yes
No
If yes, please answer the following: Date of diagnosis:
-
Month
-
Day
Year
Date
Type of treatment:
Do you test your blood glucose regularly?
Yes
No
If yes, results?
Frequency:
Last A1C Lab Test Result:
Have you ever been diagnosed with protein and/or microalbumin in your urine?
Yes
No
Any other complications? (Eye, heart, blood pressure, kidney, insulin reactions nephropathy, neuropathy, amputation, or neuropathic ulcers):
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE
No Insurance will be issued as a result of the completion of this form
Back
Next
Cancer
Have you ever been diagnosed with cancer?
Yes
No
If yes, please answer the following:
Date of diagnosis and who would have the pathology report:
Exact name and location of cancer:
Stage and grade:
If prostate cancer, please provide PSA levels:
Dates / Details of Treatment Surgery:
Is treatment ongoing or are you taking any cancer prevention medication which are prescribed by a doctor?
Yes
No
If yes, please list name, dosage, and frequency of medication below:
Cardiac
Have you been treated for heart attack (myocardial infarction) or diagnosed with a coronary disease/condition?
Yes
No
If yes, please answer below:
Date first chest pain diagnosed:
Number of diseased vessels:
Dates and details of treatments and surgery (Examples: Angioplasty, Bypass, etc.):
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE
No Insurance will be issued as a result of the completion of this form
PAGE 4
Back
Next
To the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions? Please check any that apply and provide details.
Alzheimer's Disease
Amputation
Amyotrophic Lateral Sclerosis (ALS/Lou Gehrig's Disease)
Anemia or Blood Disease/Disorder
Aneurysm
Angina or Atrial Fibrillation
Angioplasty or Heart Surgery
Angioplasty or Heart Surgery
Arthritis
Back, Bone, Joint Disorder, Broken Bones
Back, Bone, Joint Disorder,
Broken Bones
Balance Disorder
Blood Disease/Disorder
Brain Disorder
Bowel or Bladder Disease/Disorder
Bowel or Bladder Disease/Disorder
Bypass Surgery
Cardiomyopathy
Carotid or other Arterial Surgery
Carotid or other Arterial
Cerebrovascular Accident
Chronic Hepatitis
Circulatory Disease/Disorder
Circulatory Disease/Disorder
Cirrhosis
Congestive Heart Failure
Convulsions
CREST Syndrome
Cystic Fibrosis
Dementia
Disabling Back or Spine Condition
Disabling Back or Spine Condition
Difficulty Walking
Depression or Mental Disorder/Illness
Depression or Mental Disorder/Illness
Dizziness/Fainting
Spell(s)/Blacking out
Ear or Eye Disorders
Endocrine or Pituitary
Disorders
Epilepsy or Tremors
Fibromyalgia
Falls or Injuries due to Falls or Imbalance
Falls or Injuries due to Falls or Imbalance
Gastrointestinal Disorders
Genitourinary Disorders
Hodgkin's Disease
Huntington's Chorea
Heart Disease/Disorder or High Blood Pressure
Heart Disease/Disorder or
High Blood Pressure
Immune System Disease/Disorder
Immune System Disease/Disorder
Joint Replacement Surgery
Kidney Failure or received Dialysis
Kidney Failure or received Dialysis
Kidney or Liver Disease/Disorder
Kidney or Liver Dialysis
Leukemia
Lupus/Systemic Lupus
Lymph Node Disease/Disorder
Lymph Node Disease/Disorder
Macular Degeneration
Mental or Cognitive Disorder
Mental Retardation
Multiple Myeloma
Memory Loss or Frequent/Persistent forgetfulness
Memory Loss or
Frequent/Persistent
forgetfulness
Multiple Sclerosis (MS)
Muscular Dystrophy
Mini stroke or Transient Ischemic Attack (TIA)
Mini stroke
Transient Ischemic Attack (TIA)
Musculoskeletal Disorders
Myasthenia Gravis
Neurological Disease/Disorder
Neurological Disease/Disorder
Organ Transplant
Organic Brain Syndrome
Osteoporosis
Paralysis
Parkinson's Disease
Peripheral Vascular Disease
Peripheral Vascular Disease
Post-Polio Syndrome
Polymyositis
Psychosis
Respiratory Disease/Disorders
Respiratory Disease/Disorders
Rheumatoid Arthritis
Sarcoidosis
Schizophrenia
Scleroderma
Seizures
Senility
Skin Ulcers
Spinal Cord Injury
Thyroid Disease
Tuberculosis
Unexplained/Unplanned weight loss/gain
Unexplained/Unplanned weight loss/gain
Ulcerative Colitis
Vision Disorder
Weakness or Fatigue
Any other conditions causing Crippling/Limited Motion requiring Adaptive Devices
Any other conditions weight loss/gain
Motion requiring Adaptive Devices
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE No Insurance will be issued as a result of the completion of this form
PAGE 5
Back
Next
Rows
Condition(s)
Nature of Condition / Date of Diagnosis
Date Last Treated / Medication Taken
1
2
3
4
5
Please list all physicians visited in the last 5 years:
Physician's name:
Address:
Phone:
Format: (000) 000-0000.
Date last seen:
Reason:
Results:
Physician's name:
Address:
Phone:
Format: (000) 000-0000.
Date last seen:
Reason:
Results:
Physician's name:
Address:
Phone:
Format: (000) 000-0000.
Date last seen:
Reason:
Results:
Physician's name:
Address:
Phone:
Format: (000) 000-0000.
Date last seen:
Reason:
Results:
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE
No Insurance will be issued as a result of the completion of this form
PAGE 6
Back
Next
Please list any medications prescribed by any doctor, treating physician, physician's assistant, or nurse practitioner in the last 5 years:
Please list any medications prescribed by any doctor, treating physician, physician's assistant, or nurse practitioner in the last 5 years:
Rows
Medication Name
Dosage
Frequency
Reason
1
2
3
4
5
6
7
8
9
10
Family Record
Family Record
Rows
Age
State of Health
Age at Death
Cause of Death
Father
Mother
Brother(s)
Sister(s)
Existing Life and Long-Term Care Insurance
Existing Life and Long-Term Care Insurance
Rows
Company
Policy #
Issue Date
Face Amount
Owner
1
2
3
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE
No Insurance will be issued as a result of the completion of this form
PAGE 7
Back
Next
Additional or Overflow Information
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE
No Insurance will be issued as a result of the completion of this form
Back
Next
Current Assets and Financial Information
Social Security
Are you currently taking Social Security Income (SSI)? If so, what is the gross amount?
If not, what age do you currently plan to take SSI?
Are you retired?
Yes:
No:
Not yet? What age do you plan to retire?
If you have a spouse, are they currently taking Social Security Income (SSI)? If so, what is the gross amount?
If not, what age do they currently plan to take SSI?
Is your spouse retired?
Yes:
No:
Not yet? What age do they plan to retire?
Please complete if you have not yet filed for SSI. Info can be found on your SS statement:
Rows
You
Spouse
SSI @ Age 62
SSI @ Full Retirement Age
SSI @ Age 70
Gross Current Monthly Expenses (i.e. mortgage, insurance, food, utilities, taxes, etc.):
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE
No Insurance will be issued as a result of the completion of this form
PAGE 9
Back
Next
Household Income & Assets
Household Income & Assets
Rows
You
Spouse
Current Annual Income
Current or if retired, previous occupation?
Income Sources (i.e. Employer, Business, SSI, Pension, RMD, Rentals, Withdrawal's, etc.)
Checking Account(s)
Savings Account(s)
CD's Matured
Individual Annuity/Annuities
Joint Annuity/Annuities
Brokerage Account(s)
Joint Brokerage Account(s)
401(k)s
IRA(s)
Roth IRA(s)
Equities (stocks, bonds, commodities, or precious metals)
Life Insurance Cash Value
Totals
Total Household Assets Liquid and Non-Liquid
PLEASE NOTE THIS IS NOT AN APPLICATION FOR INSURANCE
No Insurance will be issued as a result of the completion of this form
PAGE 10
Preview PDF
Submit
Should be Empty: