LONG TERM CARE QUESTIONNAIRE

LONG TERM CARE QUESTIONNAIRE
Agent’s Name*
Agent’s Phone*
Format: (000) 000-0000.
Agent's Email*
example@example.com
Client Name*
Client D.O.B.*

MonthDayYear
Sex*

MaleFemale
Marital Status*
• Is client applying with spouse?

YesNo
State*
Desired Monthly Benefit*
Desired Benefit Duration*
Additional Policy specs you want included
Height*
Weight*
Lost weight in last year?*

YesNo
• If yes, how much ____ lbs. ?
What type plan do you want

Traditional Long Term CareGuaranteed Issue Long Term CareLife with Long Term CareAnnuity with Long Term CareAnnuity Income Rider with Chronic Benefit (Guaranteed issue)
Tobacco use in any form (last 5 years)?*

YesNo
• If yes, give form and frequency
Recently stopped using tobacco (last 12 months)?*

YesNo
• If yes, when
Any family history of Dementia, or Alzheimer's?*

YesNo
• If yes, list family relation and diagnosis
Are you taking any medications?*

YesNo
• List any prescribed medications taken (include dosage, frequency, and purpose)
• List any prescribed medications taken (include dosage, frequency, and purpose)
• List any prescribed medications taken (include dosage, frequency, and purpose)
• List any prescribed medications taken (include dosage, frequency, and purpose)
High blood pressure?*

YesNo
• If yes, current reading, highest reading: BP
Elevated cholesterol?*

YesNo
• If yes, current reading, highest reading: Chol
• HDL reading or ratio
Been hospitalized (last 5 years)?*

YesNo
• If yes please detail:
Any history of Cancer?*

YesNo
• Date Diagnosed?

MonthDayYear
Date
• Treatment:
• Cancer type and stage?
Any history of Diabetes?*

YesNo
• Date Diagnosed?

MonthDayYear
Date
• Type (1 or 2) and last A1C reading?
Any history of Cardiac Disease?*

YesNo
• Date Diagnosed?

MonthDayYear
Date
• Type (attack, bypass, stent, etc.)?
Any history of Sleep Apnea?*

YesNo
• Date Diagnosed?

MonthDayYear
Date
• What is current treatment (CPAP, surgery, etc.) and current AHI?
Any history of Alcohol/Drug abuse?*

YesNo
• Date Diagnosed?

MonthDayYear
Date
• Last date of in-treatment?

MonthDayYear
Date
Had any physical therapy in the last 6 months?*

YesNo
• If yes, provide details
Had a routine medical check-up within the past year?*

YesNo
• If yes, results:
Any surgery or testing recommended in the past year?*

YesNo
• If yes, provide details
Are you currently living in a facility or hospital (assisted living, nursing home)?

YesNo
Do you use a walker, cane or wheel chair?

YesNo
List other illnesses or impairments (if applicable):
Are you able to perform all 6 Activities of Daily Living without assistance (bathing, dressing, eating, toileting, transferring, continence)

YesNo
Does the client have foreign travel plans?*

YesNo
• If yes, when, where and for what duration?
The above information is for preliminary underwriting purposes only and will not be made part of any contract.
Should be Empty: