Health History Questionnaire
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- Giles Wright
- 5 years ago
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1 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, product, and ultimately the cost of a policy. Please complete the information below, providing as much detail as possible, to begin the process. I. PERSONAL INFORMATION Marital Status: q Married q Single q Divorced q Widowed q Partner/Living Together Name: Sex: q Male q Female Street Address: City: State: Zip: Home Phone: Fax Number: Work Phone: DOB: Age: Height: Weight: Name: Sex: q Male q Female Street Address: City: State: Zip: Home Phone: Fax Number: Work Phone: DOB: Age: Height: Weight: II. CAN YOU QUALIFY? (continues) Do you use devices such as a wheelchair, walker, quad cane, crutches, hospital bed, dialysis machine, oxygen, or stair lift? Please circle all that apply. Are you cognitively impaired or do you currently need or receive help in doing any of the following activities of daily living (ADLs): bathing, eating, dressing, toileting, transferring or maintaining continence? Please circle all that apply. LTC Health History Questionnaire continues
2 LTC Health History Questionnaire PAGE 2 of 6 II. CAN YOU QUALIFY? Have you had another long-term care insurance policy inforce during the last 12 months? If so, with which company: Are you currently covered by Medicaid (not Medicare)? Are you currently receiving Disability, Worker s Compensation, or Social Security Disability Benefits? Please circle all that apply. Do you intend to replace any of your medical or health coverage with the coverage applied for? (This is not medical or health insurance coverage.) Have you had a gain or loss of more than 10 pounds in the last 12 months? If yes, please explain: Have you used tobacco products (smoked, chewed or used nicotine delivery system) including pipes and cigars in the last 12 months? Please circle all that apply. Have you been advised to limit, reduce, discontinue, or seek counseling for the use of alcohol or drugs? Have you been hospitalized in the past five years? If yes, please explain: Has surgery been recommended but not performed? If yes, please explain: Have you experienced episodes of falling, fainting, dizziness or imbalance? In the last 10 years, have you been diagnosed or treated for any of the following?: - AIDS/HIV - ALS (Lou Gehrig s Disease) - Alzheimer s Disease, Dementia or Senility or Memory Loss - Congestive Heart Failure
3 LTC Health History Questionnaire PAGE 3 of 6 II. CAN YOU QUALIFY? - Asthma Or Chronic Bronchitis - Cirrhosis of the Liver - Cystic Fibrosis - Diabetes with Insulin or history of TIA or Vascular Disease - Huntington s Chorea - Hypertension or High Blood Pressure - Metastatic Cancer - Multiple Sclerosis - Muscular Dystrophy - Organic Brain Syndrome - Parkinson s Disease - Stroke or Multiple Transient Ischemic Attack - Alcohol or Drug Addiction - Amputation - Angioplasty or Heart Surgery - Cancer (please see page 6) - Carotid or other Artetial Surgery - CREST Syndrome or Scleroderma - Depression, Anxiety or Bipolar - Diabetes (please see page 6) - Disabling Back or Spine Condition - Emphysema/COPD - Epilepsy, Seizures or Convulsions
4 LTC Health History Questionnaire PAGE 4 of 6 II. CAN YOU QUALIFY? - Fainting Spells or Blacking Out - Fibromyalgia - Heart Attack, Angina or Atrial Fibrillation - Hodgkin s Disease - Immune System Disorders - Irritable Bowel Syndrome or Crohn s Disease - Joint Replacement Surgery - Kidney Failure - Leukemia - Lupus - Mental Illness - Multiple Myeloma - Myasthenia Gravis - Osteoporosis - Post-Polio Syndrome - Rheumatoid Arthritis or Osteoarthritis - Sleep Apnea If you checked Yes to any of the conditions listed on Page 3 or have been treated for a condition not listed above, please provide details below.
5 LTC Health History Questionnaire PAGE 5 of 6 What medications are you taking? When was your last physical exam? Date: Outcome: Physician: Phone Number: Address: Date: Outcome: Physician: Phone Number: Address:
6 LTC Health History Questionnaire PAGE 6 of 6 CANCER ADDITIONAL HEALTH INFORMATION When was the cancer diagnosed (Month, Year)?: What type of cancer did you have and where was it located?: At the time of diagnosis, what was the stage (1,2,3,4) and grade (A,B,D,or D)?: Were any lymph nodes positive? If so, how many?: What was the treatment protocol? Surgery? Chemo? Radiation? Combination?: When were you released from treatment (Month, Year)?: If Prostate Cancer, when was the last PSA and Gleason Score done?: What were the readings?: DIABETES ADDITIONAL HEALTH INFORMATION What type of Diabetes do you have? Juvenile Onset Type I? Adult onset Type II?: When was it diagnosed (Month, Year)?: What is the treatment? Diet Only? Oral Medicine? Insulin injections? Insulin Pump? Number of CC s or units of insulin?: When was the last blood sugar test done? What was the reading?: When was the last A1C done? What was the reading?: Have there been any complications? Foot ulcers? Vision Problems? Kidney Damage? Neuropathy?: FAMILY HISTORY Any family history of Alzheimer s/dementia? q Yes q No Grandparent/Parent/Sibling? Age of onset: Revised 6/30/17 HCB00799
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