Long Term Care Health Questionnaire
All information is kept in strict confidence and will be shared only with our professional underwriting partners for the purpose of achieving the most accurate quotes or recommendations for coverage options.
Name
*
First Name
Last Name
Best Contact Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
State of Residence for Coverage
Gender
Male
Female
Height
Weight
Marital Status
Married
Unmarried
Unmarried, but living together in committed relationship for 3+ years
Do you have a Spouse/Partner? (regardless of whether they will be covered - can lead to discounts, if so)
Yes
No
Spouse/Partner Name (please complete separate questionnaire if considering for coverage)
First Name
Last Name
Do you currently have, or have you ever been diagnosed with any of the following?
Alzheimer's Disease
Amyotrophic LateralSclerosis (ALS / Lou Gehrig's Disease)
Ankylosing Spondylitis
Congestive Heart Failure
Cystic Fibrosis
Dementia
Huntington's Chorea
Mental Retardation
Multiple Myeloma
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis
Parkinson's Disease
Schizophrenia
Spinal Cord Injury
Acquired immune deficiency syndrome (AIDS)
AIDS-related complex (ARC) or tested positive for the Human Immunodeficiency Virus (HIV)
Within the past 2 years have you been confined to a nursing home, assisted living center, received or been advised to receive hospice care, been advised that you have a terminal illness or need assistance with: bathing, eating, dressing, toileting, maintaining continence, or transferring into/out of bed, chair, or wheelchair and/or mobility concerns, including using a cane, crutch, or walker?
No
Yes
If yes to either of the previous 2 questions, please provide more detail, and click "Submit" below for review. Do not complete the remainder of the survey until our professional underwriting team has had a chance to review and determine whether to proceed.
Submit
What is prompting your interest in LTC coverage? (heard recommendation, parent or family health issue, etc)
Based on current resources (income & assets), how do you assess your ability to cover those potential costs if they were to arise for your family?
Considering all sources of other recurring income you would be able to count towards LTC and other household expenses, how much would you like to initially consider as a monthly LTC benefit to fill in the gap (i.e. $3000, $5,000, etc)?
Do any of the questions up to the dividing line on that page apply to you (e.g. you would have a "Yes" answer to them)?
Yes
No
Please provide info on any applicable questions below the line on that page to help us provide you with an accurate quote
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When was the date of your last full physical exam that included lab work? Approximate month and year is acceptable.
-
Month
-
Day
Year
Date
Provide your most recent blood pressure reading as documented by your physician? (best guess is okay)
Are you currently experiencing a fever, cough, or shortness of breath?
No
Yes
Please provide details
Any tobacco or nicotine use in the last 5 years (Includes all delivery forms; smoking, gum, patch, pill, spray, snuff, e-cigarette, vapor, etc.)
No
Yes
Please provide ALL of the following: (1) date last used (2) frequency of use (3) method of ingestion - smoke, gum, patch, vape, etc.
Do you regularly consume 4 or more alcoholic beverages per day, or do you drink 5 or more drinks per day, 1 or more days per week?
No
Yes
Please provide details
Do you use marijuana, whether for recreation or prescribed?
No
Yes
Provide details on ALL of the following: (1) indicate whether recreational or prescribed (2) if prescribed, what condition it treats (3) frequency of use (4) method of ingestion.
Have you ever received or been advised to have counseling for alcohol or drug abuse?
No
Yes
Please explain which one, whether currently receiving counseling, and if not, how long ago it was received.
Have you had any Hospitalizations, Surgeries, or Emergency Room visits in the last 10 years?
No
Yes
Please explain BOTH of the following: (1) Why (2) Approximate date- month/year if in last 12 months or just the year if over 12 months.
Other than your podiatrist, optometrist, or dentist, have you seen a specialist in the past 3 years?
No
Yes
Indicate ALL of the following: (1) type of specialist (2) Reason for seeing them (3) Approximate month/year of last visit (4) indicate if more visits are planned.
Has a medical professional recommended treatment for any condition where treatment has NOT yet started?
No
Yes
Explain BOTH of the following: (1) The recommended treatment (2) When/if it is scheduled to begin
Have you had an application for long term care insurance denied?
No
Yes
Please provide details such as (1) when (year) did this occur. (2) Reason for denial. (3) the name of the insurance company if you recall.
Are you currently receiving physical therapy, occupational therapy, or speech therapy or have you received any of those therapies in the last 12 months?
No
Yes
Provide ALL of the following (1) Type of therapy (2) What condition it is treating (3) When therapy began (4) When it ended or is scheduled to end.
Do you regularly see a Chiropractor?
No
Yes
Explain how often and reasons for your visits.
Have you been diagnosed with Degenerative Disc Disease or Spinal Stenosis?
No
Yes
Specify your diagnosis and explain what treatments you have received
Within the past 12 months have you been diagnosed or treated for any type of Seizure?
No
Yes
Please provide details.
Have you been diagnosed with Lupus?
No
Yes
Please specify if DISCOID or SYSTEMIC and your date of diagnosis (month/year if in last 12 months or just the year if over 12 months)
Within the past 24 months have you had any type of amputation caused by disease?
No
Yes
Please explain what was amputated and why.
Have you been diagnosed with Kidney Disease, Cirrhosis, Paget's disease, or any Connective Tissue Disorder?
No
Yes
Provide ALL of the following (1) diagnosis, (2) treatment plan (3) date of diagnosis (month/year if in last 12 months; otherwise, the year).
Have you had any joint replacements?
No
Yes
Explain joint(s) involved and approximate date(s) of replacement.
Have you ever been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) or Emphysema?
No
Yes
What is your specific diagnosis (COPD or Emphysema), and when were you initially diagnosed (approximate month/year).
Have you daily or intermittently used oxygen, IPPB therapy or home respiratory therapy within the past 12 months?
No
Yes
Provide details on the type(s) and date(s) of treatment.
Have you ever been diagnosed with Sleep Apnea?
No
Yes
What was the (approximate) date of diagnosis of your Sleep Apnea?
-
Month
-
Day
Year
Date
Do you use a CPAP or BiPaP?
No
Yes, CPAP
Yes, BiPAP
Is your Sleep Apnea treated in any way other than a CPAP or BiPaP?
No
Yes
Explain in more detail how it is being treated:
When was your last sleep study (approximately)?
-
Month
-
Day
Year
Date
Have you ever been treated for Hypertension (High Blood Pressure) or Any Heart Disease or Heart-Related conditions?
No
Yes
Have you been treated for Hypertension (High Blood Pressure)?
No
Yes
Please provide details on the following: (1) Approximate year of first diagnosis, (2) Average blood pressure reading, (3) Does your doctor feel your condition is controlled? (4) Are you taking medications (include name and dosage)?
Have you ever been diagnosed with Arrhythmia/Irregular Heartbeat or Atrial Fibrillation?
No
Yes
Provide ALL of the following: (1) Approximate date of diagnosis (2) The number of episodes in the last 12 months (3) Any treatment or additional details.
Have you ever been diagnosed with Cardiomyopathy, Coronary or Carotid Artery Disease or any heart disease?
No
Yes
Provide ALL of the following (1) Specific diagnosis (2) Treatments you received or are currently receiving (3) Date of diagnosis (month/year if in last 12 months; otherwise year.
Have you ever required electrical cardioversion?
No
Yes
Provide dates and result.
Have you ever experienced any symptoms of palpitations, chest pain or dizziness?
No
Yes
Please provide details.
Have you ever had a heart attack?
No
Yes
Please provide details.
Do you have any kidney problems?
No
Yes
Please provide details.
Have you ever been diagnosed or treated by a medical professional for a mental or nervous disorder, bipolar, anxiety, or depression?
No
Yes
What was or is the specific diagnosis?
Major Depressive Disorder or Atypical Depressive Disorder
Situational Depression or Chronic Dysthymia Disorder
Other or not sure (please elaborate)
Please provide any helpful info for our underwriters to consider, including: 1. Date of diagnosis? 2. Are you taking any medications? Name(s) and dosage? 3. Has this been diagnosed as situational? 4. Have you ever been hospitalized for depression, anxiety or other mental illness? Date/details? 5.Have you ever received electroconvulsive shock therapy?
Have you ever attempted suicide?
No
Yes
Please provide approximate date(s)
Have you ever been diagnosed with Diabetes?
No
Yes
What Type of Diabetes?
Type I
Type II
Juvenile
Provide the following details: (1) Age at diagnosis (2) What is your most recent blood sugar level or Hemoglobin A1C? (3) Does your doctor feel your blood sugar level is in good control? How long has it been stable? (4) Do you have any diabetes-related complications? (e.g. eye problems directly related to diabetes, kidney problems, circulatory problems, numbness and tingling of the extremities, neuropathy, or non-healing wounds or skin lesions/ulcers or amputations?
Are you taking Insulin?
No
Yes
Units/Day?
Are you taking any medication for diabetes?
No
Yes
Name(s) and dosage? Any recent changes?
Do you have any mental or cognitive limitations or symptoms of a cognitive impairment or any "memory loss" that would be noted in doctor records?
No
Yes
Please provide details, including any relevant dates of diagnosis
Have either of your biological parents or any siblings been diagnosed with Alzheimer's or other form of dementia?
Mother
Father
Both Parents
One Sibling
Two or more siblings
Combination of one or more parents and one or more siblings
None of these
Please provide additional details (age of diagnosis, current status, and length of condition)
Have you ever been diagnosed with Osteoporosis, Arthritis, Osteoarthritis, or Rheumatoid Arthritis?
No
Yes
Have you ever been diagnosed with Osteoporosis?
No
Yes
When was Osteoporosis initially diagnosed? (month/year if within last 12 months; otherwise, year is acceptable)
Has your doctor done bone density studies. If so, what were the T-scores from your last test and when was the test performed? (best estimate will suffice if you are unsure)
Please provide all of the following details: (1) Are you taking any medications? Name(s) and dosage? (2) Have you had any recent fractures (such as bone or spinal) or falls? (3) Have you had any loss in your height? (4) What is your degree of osteoporosis? (5) Do you have Degenerative Disc Disease or Scoliosis? Details... (6) What type of exercise do you engage in? Frequency?
Have you been diagnosed with any type of arthritis?
No
Yes
Type?
Osteoarthritis
Rheumatoid Arthritis
Degenerative Arthritis
Other/Not Sure
Provide date of diagnosis (approximate month/year if within the last 12 months; otherwise, year will suffice.
Please provide the following details: (1) What joints are affected and have you had any joint replacements? (2) Are you taking any medication for arthritis? Name(s) and dosage? Have you had any recent changes in medications? (3) Have you ever used steroids to treat your arthritis? How much and for how long? (4) Do you have any limits in activity as a result of your arthritis? How far can you walk without resting? Do you have any difficulty with stairs?
Are there any joint deformities related to the Rheumatoid Arthritis?
No
Yes
Please provide details:
Have there been any Rheumatoid Arthritis flare ups within the past 24 months?
No
Yes
Please provide details:
Have there been any fractures?
No
Yes
Please provide details:
Have you ever had a stroke or Transient Ischemic Attack (TIA)?
No
Yes
Was it diagnosed as a TIA or a stroke?
TIA
Stroke
Unsure
What was the date(s) of stroke or TIA episode(s)?
Please provide additional details, including: (1) What treatment you received or are receiving regarding the stroke or TIA (including medication and dosage)? (2) Are there any residual effects from the stroke or TIA? Please explain.
Have you ever been diagnosed with cancer(s)?
No
Yes
What type of cancer(s)? NOTE: If Prostate, include your most recent PSA level. Did it spread to other areas/was it diagnosed as metastatic?
What stage/grade was the cancer(s)?
What kind of treatment has been done (surgery, x-ray therapy, chemotherapy, radiation, etc), including approximate dates and when the treatment(s) ended? (For any type of cancer other than basal cell skin cancer, squamous cell of the skin or early state breast or prostate cancer, you typically must have gone at least two years without surgery or treatment.)
Were there any positive lymph nodes and how many nodes were tested (if known)?
Have there been any recurrences, complications, or residual problems? Please explain.
Do you have a handicap placard, sticker, or license plate for your vehicle that is for your use?
No
Yes
Please explain reason why it was issued to you and current status
Are you currently receiving disability benefits of any kind? (Social Security Disability, Private Insurance, VA, or any other).
No
Yes
Please provide further detail:
Other than any medications already previously provided - please include ALL of the following for any additional medication you are currently prescribed; (1) Name of medication (2) What condition is it treating (3) Dosage and frequency of use (4) Month/year it was INITIALLY prescribed- approximate year will suffice if it has been more than 12 months.
In the last 12 months, have there been changes in dosage or frequency of use of any prescribed medications (not previously mentioned)?
No
Yes
Please provide details:
Are there prescription medications that YOU NO LONGER TAKE but have taken in the last three years (excluding for cold, flu, and seasonal allergies)?
No
Yes
Please provide details:
Are you prescribed Oxygen or any Durable Medical Equipment?
No
Yes
Explain what you are prescribed and why it was prescribed.
Any cortisone or other steroid injections in the last 2 years?
No
Yes
Provide ALL of the following: (1) condition it treated (2) number of injections (3) date (month/year) of last injection (4) whether more injections are planned.
Do you currently have any other conditions or treatments not previously mentioned or anything else you'd like to share with us?
No
Yes
Explain what the condition(s), what treatment(s), current prognosis, etc., or let us know anything else you would like to share.
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