Health Questionnaire
Name of Employer
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Name of Association (If no Assn. affiliation put NONE)
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Employee Full Name
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Employee Residence Zip Code
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Phone Number
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Area Code
Phone Number
Health Plan Enrollment Option
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Employee Only
Employee/Spouse
Employee/Child(ren)
Family
I Decline Participation
List the Family Members that WILL BE On Your Health Plan
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Rows
Name
Date of Birth
M/F
Tobacco Use
Height
Weight
Employee
Spouse
Dependent
Dependent
Dependent
Dependent
Dependent
Dependent
1. Have you or any person that will be covered on your health plan been diagnosed or treated for any of the following conditions in the past 5 years?
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Rows
Yes
No
Cardiac Disorder
Cancer
Diabetes
Kidney Disorder
Respiratory Disorder
Liver Disorder
High Blood Pressure
AIDS
Alcohol/Drug Abuse
Mental/Nervous Disorder
Neuromuscular Disorder
Stomach/Gastrointestinal Problems
Seizures/Convulsions/Epilepsy
Arthritis/Back/Bone/Joint Disorder
2. Have you or any person that will be covered on your health plan had an application for insurance declined, postponed, rated or otherwise modified?
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Yes
No
3. Have you or any person that will be covered on your health plan had any medical conditions in the past 24 months requiring medical care, prescription management or hospitalization in the amount of $5,000 or more?
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Yes
No
4. Have you or any person that will be covered on your health plan anticipating hospitalization or surgery, or had any surgery or hospitalization recommended that has not been performed?
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Yes
No
5. Are you or any person that will be covered on your health plan currently pregnant or suspect they may be pregnant?
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Yes
No
If 'YES' was answered to any of questions 1-5 above please give additional detail in the space provided below. If you answered NO to 1-5 enter NONE in the Question #1 row.
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Rows
Family Member
Disease/
Diagnosis/
Treatment
Date of Onset Month/Year
Date Last Seen By Physician
Remaining Symptoms or Problems
Question #1
Question #2
Question #3
Question #4
Question #5
6. Prescriptions/Medications - Please list any medications, prescriptions or injections taken in the past 12 months. This needs to be answered on you or any person that will be covered on your health plan. If no one takes any medication enter NONE in the Medication #1 row.
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Rows
Family Member
Medication Name
Dosage
Medical Condition
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
AUTHORIZATION: My signature below hereby authorizes any physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, or other organization, institution or person that has any records or knowledge pertaining to the health of me or my dependents listed on this form to provide such information to Corporate Plan Management (Health Plan Administrator). A photographic copy of this authorization shall be considered permissible. This authorization will remain in effect for six (6) months from the date below. SIGNATURE
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Date
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Month
-
Day
Year
Date
Submit
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