TERM & UNIVERSAL LIFE GUIDELINES
|
|
|
- Sheena Dickerson
- 6 years ago
- Views:
Transcription
1 DISEASE Aids HIV ALS Lou Gehrigs Disease Aneurysm Cancer Diabetes Hepatitis Kidney Failure Home Easy Term Easy U.L. Safe Shield Strong Smart U.L. Term last 7 treated in last 7 Diagonosed prior to 35 or using insulin: last Treated within 5 WITH PILLS: Ages 1829 & Ages 3039 more than 6 years & Ages 4049 more than 16 WITH INSULIN: Ages 1849 & Ages 5059 more than 6 years & Ages 6065 more than 2 last Cerebral, Aortic, or Orthoracic: Treated in last 10 Treated with insulin: See Diabetes Build Chart. Hep A Recovered: Diabetes prior to age 50 years old: 50 and older: last treated in last 5yrs: 2 or more separate occurences: Under age 30: Hep B or C If chronic: last Treated in last Using insulin in the last last Liver Disease last Lupus Discoid: Systemic: Diagnosed less than 5 years with meds: Discoid: Systemic: Discoid: Systemic: Discoid: Systemic: In the last 5 years for systemic: Organ Transplant
2 RESPRITORY Asthma Home Easy Term Easy U.L. If mild: If hospitalized, last 12 mos, steriod use, tobacco use: Black Lung If treated : Bronchitis Chronic: Safe Shield Mild: Smoker: If treated : Strong Smart U.L. Mild: Moderate if 50lbs lighter than weight chart: If treated : Chronic: If treated : Chronic: If hospitalized more than 10 days in last 12 mos: If treated : Term last C.O.P.D. If mild: If smoker or oral the steroids in last 12 mos: Cystic Fibrosis Emphesema Smoker: If mild:. If smoker or oral steroids in last 12 mos: the the Oxygen Smoker: Pneumonia Sleep Apnia
3 MENTAL Alzheimer's Anxiety BiPolar Depression Dementia Parkinson's Schizophrenia Stress Home Easy Term Easy U.L. 2 meds or more: 2 meds or more: 2 meds or more: Safe Shield Strong Smart U.L. last If mild and controlled: If hospitalized because of, last last If mild and controlled: If hodpitalized because of, 3 or more meds or hospitalized in last 2 3 or more meds or hospitalized in last 2 3 or more meds or hospitalized in last 2 last If mild: Severe: last If mild and controlled: If hodpitalized because of, 3 or more meds or hospitalized in last 2 Term the the the the
4 DIGESTIVE SYSTEM Home Easy Term Easy U.L. Safe Shield Strong Smart U.L. Term Acid Reflux Heart Burn Crohn's Gastric ByPass Diagnosed prior to 20 years old or last 1 year: Surgery in last 12 mos: If no flareup in last 3 More than 5 yrs in remission: Within 1 year: Surgery in last 6 mos: Sarcoidosis Ulcerative Colitis If pulmonary: Diagnosed prior to 20 years old or last 1 year: the last 10 years for Pulmonary: If no flareup in last 3 If pulmonary: If localized, nonpulmonary: Severe: Mild:
5 SKELETAL SYSTEM Arthritis Amputation Home Easy Term Easy Rheumatoid U.L. severe: Caused by disease: Safe Shield Rheumatoid severe: If due to diabetes: Strong Smart U.L. Rheumatoid severe: Caused by disease: Term Unless treated with: Enbrel, Remicade, or Humira: Last 2 Fibromyalgia Pain Medications No depression and working full time: Walker / Wheelchair / Cane Permanent use of walker / wheelchair or scooter: Permanent use If usage in last of walker / wheelchair or scooter: 12 months:
6 CIRCULATORY SYSTEM AFIB (Atrial Fibrillation) Angioplasty / Stent Blood Pressure Circulatory Surgery Congestive Heart Failure Home Easy Term Easy U.L. last 7 Safe Shield 3 or more medications to control: Strong Smart U.L. If weight is 50 lbs under limit on chart: Last 10 years if hospitalized: If diagnosed over 2 years ago & current age 50 years or older: 4 or more meds to control: Term Treatment or occurred last 5 Occurance or treated in Irregular Heart Beat Heart Attack Heart Surgery Pace Maker / Defibrillater If treated ever last 7 with meds: Stroke
7 LIFESTYLE ISSUES Page 1 of 2 Alcohol Treatment Home Easy Term Easy If in the U.L. last 4 Safe Shield Strong Smart U.L. Term Had treatment in the Aviation Commercial: Student Pilot: If minor: In last 2 years, if minor: Within last 2 years or in the next 2 If currently or plan to be: Citizenship Private Pilot more than 100 solo hours: See "Citizenship Questionnaire" for requirement Need: permanent U.S. resident card or holding permanent Visa & S.S. # See "Citizenship Questionnaire" for acceptance If not, must complete the "Foreign National Questionnaire" Permanent resident or green card holder: Declined for Life Insurance Disabled Receiving disability payments: If for maternity or for skeletal system: With explanation of status: If declined in last 2 Driving Record Drug Abuse Treatment D.U.I. (Driving Under Influence) 3 moving violations in last 3 4 If in last 3 3 or more moving violations in last 3 5 years used or been treated: If in last 3 Last 5 years, had 4 or more moving violations: One D.U.I. in last 12 mos or 2 D.U.I.s in last 5 Last 5 years, 4 or more moving violations or a wreckless driving conviction: Used or convicted of possesion in last If in last Drug use in last 12 months or drug treatment, If in
8 LIFESTYLE ISSUES Page 2 of 2 Extreme Sports Felony Home Easy Term If in last 3 Safe Shield If minor or frequent: If in Strong Smart U.L. In last 2 years, if minor: one year or in jail in last one year: If in the next 2yrs Motor sports racing, Boat racing, Sky diving, Hang gliding, Base jumping, Rock mountain climbing: If in last 10 Mountain climbing, Auto racing, Motor boat racing, Scuba more than 100ft or 10 dives per year: If in last Term If currently or plan to be: If in last License Suspended / Revoked Marijuana Currently suspended or revoked: If illegal in their state, see "Drug Abuse" License suspended or revoked in last 3 See D.U.I. driving record. Smoker rate Awaiting felony: If suspended or revoked for reckless driving or 4 or more moving violations in the If illegal in their state, see "Drug Abuse" If within last 5 If illegal in their state, see "Drug Abuse" Parole If in last 6 months: If in last 3 If in last 1 If currently: Currently on parole from felony: Probation If within the last 6 months: If in last 3 If in last 1 If currently:
Term & Universal Life Guidelines - Simplified
- G.U.L. AIDS Alcoholism Within past 4 years: Within past 4 years: Within past 5 years: After 5 years, without relapse, no current use: : After 5 years since treatment: Less than 5 years: POSSIBLE STANDARD
FORESTERS: COLUMBIAN FINANCIAL GROUP: Smart U.L. Strong Foundation. Safe Shield. After 5 years, without relapse, no current use: ACCEPT
AI Alcoholism Within past 4 years: Within past 4 years: Within past 5 years: After 5 years, without relapse, no current use: Within past 10 years: Alcohol Abuse: After 5 years since last treatment and
CFG: Dignified Choice AGE 25-85
DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE 45-85 CFG: Dignified Choice GE 25-85 impairment Transmerica: GE 45-85 decisions Oxford: ssurance
FINALEXPENSEDOJO.COM
HEALTH CHEAT SHEET MOST COMMON CONDITIONS ALWAYS GI OXYGEN, AIDS/HIV, DEMENTIA/ALZHEIMER'S LUNG/BREATHING PROBLEMS ~COPD - LBL (STD) ~CHRONIC ASTHMA - AMERICO EAGLE LEVEL DIABETES ~PILLS & INSULIN - AMERICO
*********Americo, Foresters and CFG include medication use in decline timeframe*********
*********Americo, Foresters and CFG include medication use in decline timeframe********* Conditions Americo Ultra Protector Americo Eagle Premier Mutual of Omaha Living Promise Transamerica 45-85 Foresters
Field Underwriting Quickview
Field Underwriting Quickview For a selected list of medical conditions, the Field Underwriting Quickview outlines possible classifications and the circumstances when coverage may not be. For coverage provided
Face Amount Max Premium $ /yr. UL WL Term Survivorship
Please answer all questions applicable to the client s medical history. Producer Name Phone Fax Client Name of Birth Male Female Face Amount Max Premium $ /yr. UL WL Term Survivorship Does the client currently
Face Amount Max Premium $ /yr. Term Permanent
Please answer all questions applicable to the client s medical history. Producer Name Phone Client Name of Birth Male Female Face Amount Max Premium $ /yr. Term Permanent Has the client ever used any form
Health History Questionnaire
LTC Health History Questionnaire The first step in long-term care expense planning is determining insurability. Long-term care insurance is medically underwritten. Health history will determine carrier,
Phoenix Remembrance Life
Phoenix Remembrance Life Field Underwriting Guide For agent use only. Not for distribution to the public as sales literature. Phoenix Remembrance Life is whole life insurance underwritten on a simplified
Rapid Decision Term Rate Class Criteria Guide: Standard or Better, Table B, Table D
Rapid Decision Term Rate Class Criteria Guide: Standard or Better, Table B, Table D Table Ratings for Rapid Decision Term are ONLY AVAILABLE using Fidelity Life s RAPID APP 2 (Online Application Technology)
Welcome to the Healthplex!
Welcome to the Healthplex! Program Please check program that applies to you. If unsure, please ask our staff. Aftercare Employee Health Pulmonary Rehab Lung Gym Cardiac Rehab Health Improvement Prenatal/Post-Partum
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We
ITG Diet Health Status Intake Form
Health Status Intake Form Date: Last Name: First Name: D.O.B: Address: City: ST: ZIP Phone: Cell: Email: Age: HT: WT: BMI: Fat %: Occupation: Sex: M F Marital Status: M S D W How did you hear about the
Evolve180 / Ideal Northwest Health Profile
Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital
Quote Request. Advisor Information. Client Information. Medical History. Driving History. Advisor Company Date. Phone Fax.
Advisor Information Advisor Company Date E-Mail Phone Fax Client Information Client Name Date of Birth Occupation Plan and amount of insurance requested: Has the case been submitted to other companies
CHRONIC CONDITIONS FYI
CHRONIC CONDITIONS FYI AIDS More than 2,500 cases of HIV/AIDS have been identified in Nebraska. ALS (Amyotrophic Lateral Sclerosis) Approximately 95 people in Nebraska have ALS. As many as 800 Nebraskans
311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship
Robert Antonelle, M.D. White Plains Gastroenterology 311 North Street, Suite 403 White Plains, NY 10605 Patient Demographics Patient s Last Name First Name Middle Initial SSN Date of Birth Age Gender F
Last Name: First Name: Address: Apt/Unit #: City: State: Zip: Best Contact Phone Number: Date of Birth: Age: Profession:
Health Profile Our 30/10 program is intended to help participants with their personal weight loss efforts. We are not a medical facility, and our staff cannot give you medical or psychological advice.
PATIENT DEMOGRAPHIC INFORMATION
PATIENT DEMOGRAPHIC INFORMATION Patient Name: (First, MI, Last) Sex: [ ] M [ ] F Birth Date: Age: SS#: Email: Race: Ethnicity: Language: Mailing Address: Work Ph: ( ) City: State: Zip Code: Home Ph: (
Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:
Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Patient Information Patient Name: DOB: Last First M.I. Home Address: City:_ State:
MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No
MEDICAL HISTORY Please mark YES or NO and fill in appropriate blanks as needed Chronic Yes No If yes, year diagnosed Previous Nephrologist Transplant Yes No If yes, date Donor type Living Deceased Related
Medical Reference Library Table of Contents
Medical Reference Library Table of Contents Alcoholism Anemia Anxiety Abdominal Aortic Aneurysm Asthma Atrial Fibrillation Attention Deficit Hyperactivity Disorder (ADHD) Barrett s Esophagus Bipolar Disorder
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018 WALK INS ARE ACCEPTED BUT WE ADVISE STUDENTS TO PRE-REGISTER BEFORE THURSDAY
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs January 201 DATE DAY TIME TOPICS January 04 January 11 January 1 January 25 9:00AM 9:00AM 9:00AM 9:00AM 1. Understanding Fibromyalagia 2. Diabetes
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2019
January 2019 DATE DAY TIME TOPICS TOTAL January 03 1. Alcoholism 2. Nutrition for the Elderly 3. Uterine Fibroids 4. HIPAA 5.Arthritis 6. Childhood Obesity January 10 1. Understanding Epilepsy: Latest
FOR ADVISOR USE ONLY LIFE INSURANCE UNDERWRITING GUIDE
FOR ADVISOR USE ONLY LIFE INSURANCE UNDERWRITING GUIDE 2016 FIELD UNDERWRITING GUIDE About this Guide................ 1 Important Information to Collect When Completing the Application........ 1 Smoking
Do you exercise? Yes No If yes, what kind? How often?
HEALTH PROFILE Dietary consultation involves a health profile which purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss plan.
PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: Internet: Fax:
PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: 412-221-7640 Internet: www.davidprovenzanomd.com Fax: 412-490-9850 301 Ohio River Boulevard, Suite 203 Edgeworth Medical Commons Sewickley, PA 15143 INITIAL
Demographic and Diagnostic Profile of Study Participants
Demographic and Diagnostic Profile of Study Participants Enrollment Progress to Date 1,792 participants enrolled as of July 26 th 588 Full-Service participants 606 Basic-Service participants 598 Usual
NurseAchieve. CHAPTERS INCLUDED IN THE NURSEACHIEVE COMPREHENSIVE NCLEX REVIEW NURSING SKILLS AND FUNDAMENTALS:
NurseAchieve www.nurseachieve.com CHAPTERS INCLUDED IN THE NURSEACHIEVE COMPREHENSIVE NCLEX REVIEW NCLEX TEST STRATEGIES: NCLEX EXAM OVERVIEW TEST TAKING STRATEGIES NURSING SKILLS AND FUNDAMENTALS: ADMINISTRATION
Medical Declaration Form. Important information to read before completing the form:
Administered by Medical Declaration Form Important information to read before completing the form: Pre-Existing Medical conditions Travel insurance only provides cover for emergency medical events that
Legacy Weight and Diabetes Institute New Patient Information
Legacy Weight and Diabetes Institute New Patient Information Answering these questions will help your providers understand your health and how best to treat you. If you need help filling out this form,
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
INDIVIDUAL UNDERWRITING
GUIDE TO INDIVIDUAL UNDERWRITING life & health FOR ADVISOR USE ONLY ABOUT EQUITABLE LIFE OF CANADA Equitable Life is one of Canada s largest mutual life insurance companies. For generations we ve provided
PERSONAL PENSION LIFE INSURANCE
PENSIONS INVESTMENTS LIFE INSURANCE PERSONAL PENSION LIFE INSURANCE DATA CAPTURE FORM - BROKERAGE PLEASE READ THE QUESTIONS CAREFULLY BEFORE ANSWERING THEM AND USE BLOCK CAPITALS. If any item is blank
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018
January 201 DATE DAY TIME TOPICS TOTAL January 04 1. Understanding Fibromyalagia 2. Diabetes and Cardiovascular Disease 3. Prostate Cancer 4. Hepatitis C 5. Understanding Hepatitis B January 11 1. Dysphagia
CHRONIC CONDITIONS FYI
CHRONIC CONDITIONS FYI AIDS More than 2,500 cases of HIV/AIDS have been identified in Nebraska. Nationwide, this number is more than 1.2 million. ALS (Amyotrophic Lateral Sclerosis) There are 87 people
Health History Form Please Fill Out Entire Form
Health History Form Please Fill Out Entire Form Name: Primary Physician: Referring Provider: Review of Symptoms: Check all that apply Date of Birth: Phone: Additional Concerns: Eyes: Blurry Vision Burning/Dryness
Patient Interview Form
Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more White Unknown
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
This page is for information. Do not submit.
This page is for information. Do not submit. AISH Application - Part B Medical Report Information for Physicians Your patient (the applicant) is applying for the Assured Income for the Severely Handicapped
Phillips Brayford Orthopaedics 48 Tunnel Rd, Suite 203 Pottsville PA Phone: Fax: PATIENT INFORMATION
PATIENT INFORMATION Name: Date of Birth: Family Physician: Referring Physician: Height: Weight: Marital Status: Single Married Separated Widowed Divorced Employment Status: Employed Unemployed Disabled
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Emergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name
TELL US ABOUT YOU (please print) First MI Last Address 1 Address 2 CITY ST ZIP COUNTRY E-mail Opt out of providing E-mail Address Language Preference SSN - - DOB / / Driver s License # ST Phone 1 CELL
Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age
Health Profile ALTH PROFILE Dietary consultation involves a health profile which purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss
Pain Interventions 30 Hagen Drive, Suite Culver Rd. Suite 2 Rochester, NY Rochester, NY (Voice) (Fax)
Pain Interventions 30 Hagen Drive, Suite 230 2619 Culver Rd. Suite 2 Rochester, NY 14625 Rochester, NY 14609 (Voice) 585.899.3450 (Fax) 585.899.3454 We would like to welcome you to our office. For the
ULTIMA. series UNDERWRITING GUIDE. Accidental Death Universal Life Competitive Term Products Accidental Death Un
Accidental Death Universal Life Competitive Term Products Accidental Death Un ULTIMA UNDERWRITING GUIDE series This may not be copied, reproduced, or shown to members of the public. Agent use only. 52072
PATIENT HISTORY QUESTIONNAIRE
PATIENT HISTORY QUESTIONNAIRE The information requested in this questionnaire is very important. To give you the best care and to obtain your insurance approval, we must have complete answers. If you are
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
Eligibility. Information about you. Information about your agent Only complete this section if you have an agent
Visitors to Canada Detailed medical questionnaire Underwritten by CUMIS General Insurance Company, a member of The Co-operators group of companies. How to complete this form: Complete one form for each
1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:
Patient History Information Patient Name: Height: ft in. Weight: lbs. 1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:
Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company.
canadian expatriates visitors to canada inpatriates to canada Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company. How to complete this form: Complete one form for each person
(Title) First Name MI Last Name Maiden Name Suffix. What do you prefer to be called?
516 South Division Street, Suite 105 Cedar Falls, IA 50613-2381 Tel 319.268.3990 Fax 319.268.3995 Patient Demographic Information: Date (Title) First Name MI Last Name Maiden Name Suffix What do you prefer
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
Clinic Adult Patient Demographics
Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) - May we leave
Eligibility. Information about you. Information about your agent Only complete this section if you have an agent
Canadian Expatriates Visitors to Canada Inpatriates to Canada Detailed medical questionnaire Underwritten by CUMIS General Insurance Company, a member of The Co-operators group of companies. How to complete
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
Underwriting Handbook for Advisors
Underwriting Handbook for Advisors Life Insurance Individual Insurance Contents About this Handbook 3 How this Handbook is organized 4 Acronyms and short forms used in this Handbook 4 Medical Impairments
Mailing Address: Street City Zip
First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic
Health Profile. Last Name: First Name: Address: Apt/Unit: # City: State: Zip/Postal Code: Phone: Cell:
1 Health Profile Date: / / / Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
Southwest Service Life Insurance Company
Southwest Service Life Insurance Company UNDERWRITING GUIDE 2/2012 95587v1Proof.indd 1 95587v1Proof.indd 2 95587v1Proof.indd 3 Acne A A A ADD A A A Addison s Disease D A D AIDS, ARC, HIV Infection D D
CHRONIC TREATMENT GUIDELINES
CHRONIC TREATMENT GUIDELINES REGISTRATION OF CHRONIC CONDITIONS You can only access benefits for chronic medication, as listed below, if your prescribing/treating doctor or pharmacist registers your chronic
Our Specified Illness Benefit Is Now Even Better.
Our Specified Illness Benefit Is Now Even Better. Now Covering 47 Specified Illnesses 20 Partial Payment Illnesses Enhancements to our Specified Illness Benefit We have made enhancements to our Specified
Bariatric Surgery Program Patient Health Questionnaire. This form must be completed and returned at your Bariatric Education Class.
The Center for Weight Loss Surgery 111 Osborne Street Danbury, CT, 06810 203.739.7131 / 203.739.1669 fax Bariatric Surgery Program Patient Health Questionnaire Name: DOB: Please answer the following questions
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
Weight 1 year ago (lb):
Health Profile Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order to guide his
Field underwriting pocketbook for life and critical illness insurance
500-5000 Yonge Street Toronto, Ontario M2N 7J8 www.ivari.ca ivari and the ivari logos are trademarks of ivari Canada ULC. ivari is licensed to use such marks. BW-LP1540 9/15 Field underwriting pocketbook
Apt. /unit: City: State: Zip Code:
Health Profile Date: Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order to guide
Cannot consider Cannot consider Cannot consider
Field Home Office Absence Seizures Petit Mal Minor Epilepsy These are names for generalized seizures that are manifest by brief attacks of altered consciousness, confusion, a dazed look or staring. Date
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE. Cranial Health History Form
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE Cranial Health History Form Welcome to the Neurosurgery Department at Washington University. To help us treat you, please fill this form out completely. Your Name:
Mercy MS Center New Patient Information
Mercy MS Center New Patient Information Last Name: First Name: DOB: MULTIPLE SCLEROSIS HISTORY Reason for clinic visit: I have been diagnosed with MS or NMO (Date diagnosed ) I have not been diagnosed
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male
CHIRO-MED.Excellence in Chiropractic Medicine
CHIRO-MED.Excellence in Chiropractic Medicine \~32()0 WI--:ST MAl STREE',V 1480 NORTH CRU~N MOUNT RD. 11I':U,EVILLE, IL 62226 O'FALLON, IL 62269 () I1
Patient Health History
Patient Health History This information is very important in your care. Please complete as carefully and accurately as possible. Name: Date: Height: inches Weight: lbs Age: Symptoms: 1. Type of symptoms
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
Primary Care Clinic Adult Patient Demographics
Primary Care Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) -
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
Patient Interview Form
Page 1 of 5 Physicians: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Physicians: Samuel J. Tarwater, MD Travis J. Rutland, MD Ashwani Kapoor, MD Pathologist:
EXAM BY M.D. O yes. O ft/in O cm. O lb O kg. O yes O no. O unknown. O no 1. LIFE INSURED 2. PERSONAL INFORMATION 2.1 RELATED MEDICAL INFORMATION
EAM BY M.D. 1. LIFE INSURED Name (first, middle, last) Date of birth (dd/mmm/yy) 2. PERSONAL INFORMATION Do you have a regular physician/nurse practitioner? If yes, please provide the following (If your
PATIENT MEDICAL HISTORY FOR B.O.L.D. (Please check the most appropriate answer. If you have any questions please call the office for assistance)
Name: Date of Birth: Date: Race: Caucasion African American Hispanic Native American Pacific Islander PATIENT MEDICAL HISTORY FOR B.O.L.D. (Please check the most appropriate answer. If you have any questions
NEW PATIENT INFORMATION RECORD PATIENT INFORMATION
Zumbro Vein Institute NEW PATIENT INFORMATION RECORD PATIENT INFORMATION 501 Blackburn Drive Martinez, GA 30907 706-854-8340 Fax: 706-854-8341 www.veinsaugusta.com First Name: Last Name: MI: Social Security
HEALTH HISTORY. Occupation: Full-time (>35 hours) Disabled Homemaker. Part-time (<35 hours) Retired Student
HEALTH HISTORY Patient Information Social History Family History Patient Name: Female Male Date of Birth: Current Age: Height: Feet Inches Current Weight: lbs Highest weight: lbs Weight at age 18 lbs I
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: Address: Relationship: Address:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: ( ) Marital Status: Married Single Divorced Widowed Cell Phone: (
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
MEDICAL/SURGICAL HISTORY FORM
MEDICAL/SURGICAL HISTORY FORM / / Date: / / Surgical Patients Only: Please check the weight loss procedure that you are interested in: Gastric Bypass Lap Band Undecided Revision of Previous Surgery HT
ADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
Simplified Issue Underwriting and Medical Impairment Guide
Underwriting Guide UNDERWRITING GUIDE Simplified Issue Underwriting and Medical Impairment Guide SagicorLifeUSA.com Table of Contents 3 Simplified Issue Application Submission Process 3 Our Simplified
FROST FAMILY MEDICINE
Patient Information (Please Sign and return to Receptionist) Home Phone Day Phone Cell Phone E-mail Driver s License # Preferred Language Race Soc Sec # Gender: Male Female Marital Status: Single Married
Highland Colony Dental- Donald K. Givan, DMD
Highland Colony Dental- Donald K. Givan, DMD ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRAcTICES *You May Refuse to Sign This Acknowledgement* I, have received a copy of this office s Notice of Privacy
Please review the below items in preparation for your visit.
2001 Santa Monica Blvd., Suite #760W Santa Monica, CA 90404 (310) 582-7474 (Office) (310) 582-7481 (Fax) http://california.providence.org/saint-johns/services/orthopedics/ http://www.totaljoints.net/ Dear
First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age
Date Time Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client's health status in order to guide his or her weight loss plan. A
Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number Relationship to patient
Advocate Condell Wound Healing Center 801 South Milwaukee Ave, West Tower Libertyville, IL 60048 847-990-5670 Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number
INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
Weight 1 year ago (lb):
Health Profile Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order to guide his