Step 1 of 9 11% Cost of Long-Term Care (LTC) Insurance: Some clients are surprised by the cost of LTC insurance. The cost will vary depending on your age, gender, health, and amount of benefits. High quality LTC coverage could cost anywhere between $200-$1,000/mo. We can provide some options to lower the premium and coverage, so please let us know if you have a specific budget.Before beginning, you'll want to have: Current medication information, including the name(s) and dosage and a list of any medical procedures, including dates, within the last 10 years. If you have that info handy, let's get started!CLIENT INFOName(Required) Date of Birth(Required) Gender(Required) Male Female Are you a U.S. citizen?(Required) Yes No Are you a permanent resident?(Required) Yes No Marital Status(Required) Married Live with partner Single Will your spouse/partner be applying for coverage?(Required) Yes No Will your spouse/partner be applying for coverage?(Required) Yes No Do you have a specific max budget for LTC insurance?(Required) Yes No Unsure Some clients are surprised by the cost of LTC insurance. The cost will vary depending on your age, gender, health, type of policy, and amount of benefits. High quality LTC coverage could cost anywhere between $200-$1,000/mo. We can provide some options to lower the premium and coverage, if necessary. What's your max monthly budget?(Required) Have you ever been declined, rated or denied reinstatement for long-term care insurance?(Required) Yes No Name of company, date, and reason(Required) Do you CURRENTLY have another long-term care insurance, nursing home and home care, nursing home only, home health care, accident and health policy or certificate in-force (including a health care service, health maintenance organization, Medicare Supplement contract or life insurance/annuity with long-term care coverage)?(Required) Yes No Provide details:(Required) Do you intend to REPLACE any of your long-term care coverage, nursing home and home care, nursing home only, home health care, medical or health insurance coverage with the policy for which you are applying?(Required) Yes No Have you had another long-term care insurance, nursing home and home care, nursing home only, home health care policy or certificate in-force during the last 12 months?(Required) Yes No Provide details:(Required) Are you currently eligible for benefits under or covered by or received Medicaid, Disability Income, Worker's Compensation, Social Security Disability or any Federal or State Disability Plan?(Required) Yes No Please provide details.(Required) HEALTH INFOHeight(Required)Under 4'8"4'8"4'9"4'10"4'11"5'0"5'1"5'2"5'3"5'4"5'5"5'6"5'7"5'8"5'9"5'10"5'11"6'0"6'1"6'2"6'3"6'4"6'5"6'6"6'7"6'8"6'9"6'10Over 6'10"Weight (at doctor's office)(Required) Have you had any weight loss in the last 12 months?(Required) Yes No Amount of weight loss(Required) Reason for weight loss(Required) Do you or have you ever used tobacco products or marijuana?(Required) Yes No Are you a current user?(Required) Yes No What form of tobacco or marijuana?(Required) When did you last use tobacco or marijuana?(Required) Have you tested positive for COVID?(Required) Yes No Approximate Date of Positive COVID Test(Required) Were you hospitalized?(Required) Yes No Any residual symptoms from COVID?(Required) Yes No Provide details:(Required) Do you currently use any of the following?(Required) Wheelchair Walker Nebulizer Electric Scooter Quad Cane Oxygen Hospital Bed Respirator Kidney Dialysis Crutches Stair lift NONE OF THE ABOVE Have you been confined to, or been advised to have, or used any of the following:(Required) Residential Care Assisted Living or Adult Day Care Facility Services Nursing Home or Home Health Care Services Long-Term Care Facility Hospital NONE OF THE ABOVE Have you ever received OR currently receiving OR have been recommended to receive but haven't completed yet: physical, occupational, or speech therapy?(Required) Yes No Provide reason, details, and date(s):(Required) Have you received inpatient or outpatient treatment at a hospital, surgical center or rehabilitation facility in the past 5 years?(Required) Yes No Provide reason and date(s):(Required) Do you require assistance or supervision of another person or a device of any kind for any of the following?(Required) Bathing Toileting Dressing Eating Walking Medication management Getting in and out of a chair or bed Control of bowel or bladder NONE OF THE ABOVE Do you require assistance with shopping, using transportation or housekeeping/cooking?(Required) Yes No Do you have (for your use) a handicap parking sticker or handicap license plate?(Required) Yes No Are you taking or have you taken any prescription medication(s) within the past 3 years or are you currently taking any over-the-counter medications?(Required) Yes No Provide details on medications(Required)Medication NamePurposeDate First PrescribedFrequencyDosageDate of Last Dosage Change Add RemoveType N/A if not applicable.In the past 3 years, were you prescribed a medication but didn't take it?(Required) Yes No Provide details:(Required) When was your last physical and full lab work completed?(Required) When was your last doctor visit for any reason?(Required) Provide details:(Required) Are you scheduled for, or have you been advised by a physician or health care provider, to have additional testing, surgery or consultation(s) to evaluate health?(Required) Yes No Provide details:(Required) Are there any pending test results which you have not yet received?(Required) Yes No Provide details:(Required) Have you had any recent lab work or testing that has back abnormal or shown elevated PSA levels?(Required) Yes No Provide details:(Required) In the past 24 months, have you had to or been advised by a member of the medical profession to limit, reduce, discontinue or restrict any activities or hobbies?(Required) Yes No Provide details:(Required) Have you ever told your doctor you're experiencing memory decline or loss?(Required) Yes No Provide details:(Required) Has your biological mother, father, sibling or grandparent been diagnosed with Alzheimer's, Dementia or another cognitive impairment?(Required) Yes No Who was diagnosed?(Required) Mother Father Sibling(s) Grandparent(s) Age of onset - mother(Required) Age of onset - father(Required) Age of onset - sibling(s)(Required) Age of onset - grandparent(s)(Required) MEDICAL CONDITIONS:Neurological / Mental Disorders / Nervous SystemTo the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?(Required) Alzheimer's Disease Amyotrophic Lateral Sclerosis (ALS) Bipolar Disorder Brain Disorder Cerebrovascular Disease Cerebrovascular Accident / Stroke Dementia Depression or Mental Illness / Disorder Dizziness / Vertigo Epilepsy / Seizures Huntington's Chorea Memory Loss or Frequent / Persistent Forgetfulness Mental or Cognitive Disorder Mental Retardation Mini-stroke or Transient Ischemic Attack (TIA) Neurological Disease / Disorder Schizophrenia / Psychosis Senility Tremor Neuropathy Parkinson's Disease NONE OF THE ABOVE BIPOLAR DISORDER: When were you diagnosed?(Required) Any history of hospitalization(s)?(Required) Yes No Date(s):(Required) Does the condition limit any of your regular activities?(Required) Yes No Provide details:(Required) BRAIN DISORDER: When were you diagnosed?(Required) What is the condition you've been diagnosed with?(Required) CEREBROVASCULAR DISEASE: When were you diagnosed?(Required) Is there evidence of white matter changes or small vessel disease?(Required) Yes No Is there brain atrophy / volume loss?(Required) Yes No Any findings of lacunar infarct(s)?(Required) Yes No CEREBROVASCULAR ACCIDENT / STROKE: Date of accident / stroke:(Required) Was it a single event or multiple occurrences?(Required) Yes No Any residual impairment (weakness, slurred speech, mobility problems, etc)?(Required) Yes No Has there been a 100% recovery?(Required) Yes No DEPRESSION OR MENTAL ILLNESS / DISORDER: When were you diagnosed?(Required) Name of condition you've been diagnosed with:(Required) Any history of psychiatric hospitalization(s):(Required) Yes No Date(s):(Required) Does the condition limit any of your regular activities?(Required) Yes No DIZZINESS / VERTIGO: When were you diagnosed?(Required) Has the condition been worked up and ruled benign?(Required) Yes No Were there any associated falls?(Required) Yes No Was it a single event or multiple occurrences?(Required) Single Multiple Date(s):(Required) Does the condition limit any of your regular activities?(Required) Yes No EPILEPSY / SEIZURES: When were you diagnosed?(Required) Type of seizure diagnosed:(Required) Frequency of seizures:(Required) Date of last seizure:(Required) TRANSIENT ISCHEMIC ATTACK: When did the TIA(s) occur?(Required) How was it treated?(Required) Single or multiple episodes?(Required) Single Multiple Do you have any residual effects?(Required) Yes No Do you have any limitations?(Required) Yes No NEUROLOGICAL DISEASE / DISORDER: When were you diagnosed?(Required) What is the name of your disorder?(Required) What symptoms do you experience?(Required) Do you have any limitations?(Required) Yes No Has the condition been stable for 12 months?(Required) Yes No TREMOR: When were you diagnosed?(Required) What is the type of tremor you've been diagnosed with?(Required) Is it considered progressive or stable?(Required) Progressive Stable Do you have any limitations?(Required) Yes No Has the tremor been fully evaluated?(Required) Yes No NEUROPATHY: When were you diagnosed?(Required) What is the cause?(Required) What symptoms do you experience?(Required) Is it considered mild, moderate or severe?(Required) Mild Moderate Severe Do you have any limitations?(Required) Yes No Additional comments: MEDICAL CONDITIONS:Cardiovascular / CirculatoryTo the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?(Required) Abnormal Blood Pressure Anemia or Blood Disease / Disorder Aneurysm Angioplasty / Heart Surgery / Bypass Surgery Atrial Fibrillation Cardiomyopathy Carotid Artery Disease Congestive Heart Failure Coronary Artery Disease Defibrillator Heart Attack Heart Valve Disorder Peripheral Vascular Disease NONE OF THE ABOVE ABNORMAL BLOOD PRESSURE: Date of diagnosis:(Required) Average Blood Pressure Readings:(Required) ANEMIA OR BLOOD DISEASE / DISORDER: When were you diagnosed?(Required) What is the condition you've been diagnosed with?(Required) What is the underlying cause?(Required) Are you receiving or have you received other treatment?(Required) Yes No Have your labs been normal?(Required) Yes No Please explain:(Required) ANEURYSM: When were you diagnosed?(Required) What type of aneurysm/location?(Required) Is it resolved or still present?(Required) Resolved Still Present What was the size at diagnosis?(Required) What is the current size?(Required) How was it treated?(Required) ANGIOPLASTY / HEART SURGERY / BYPASS SURGERY: Date of procedure:(Required) Reason for procedure:(Required) Any history of heart attack or heart failure?(Required) Yes No Date(s):(Required) Are you currently experiencing any cardiac symptoms?(Required) Yes No ATRIAL FIBRILLATION: When were you diagnosed?(Required) Single episode or recurrent?(Required) Single episode Recurrent Date of last episode:(Required) Any history of ablation or cardioversion?(Required) Yes No Date(s):(Required) CARDIOMYOPATHY: When were you diagnosed?(Required) Is the cardiomyopathy considered Hypertrophic/Ischemic, Dilated or Restrictive?(Required) Hypertrophic / Ischemic Dilated Restrictive When was the last time you experienced symptoms?(Required) Any presence of implantable defibrillator?(Required) Yes No Do you know your last ejection fraction reading?(Required) Yes No CAROTID ARTERY DISEASE: When were you diagnosed?(Required) Any surgery?(Required) Yes No Date(s):(Required) Is it resolved?(Required) Yes No CONGESTIVE HEART FAILURE: When were you diagnosed?(Required) Was it a single event or multiple occurrences?(Required) Single Multiple Date(s):(Required) Did you make a full recovery?(Required) Yes No CORONARY ARTERY DISEASE: When were you diagnosed?(Required) Any surgical procedures?(Required) Yes No Date(s):(Required) Do you experience any symptoms such as shortness of breath, chest pain, fatigue?(Required) Yes No Do you go for regular cardiac follow-up visits?(Required) Yes No Date of last cardiac testing:(Required) Were results normal?(Required) Yes No DEFIBRILLATOR: Date of defibrillator placement:(Required) Has the defibrillator ever fired?(Required) Yes No HEART ATTACK: Date of heart attack(s):(Required) Any related surgeries or procedures as a result of the heart attack(s):(Required) Yes No Date(s) and details:(Required) Do you currently experience any chest pain or discomfort?(Required) Yes No HEART VALVE DISORDER: What is the name of the disorder?(Required) When was it diagnosed?(Required) Any related surgeries or procedures for the disorder?(Required) Yes No Date(s):(Required) If valve replacement surgery, was a bovine or mechanical valve used? Bovine Mechanical PERIPHERAL VASCULAR DISEASE: When were you diagnosed?(Required) Is it considered mild, moderate or severe? Mild Moderate Severe Any history of leg ulcers or other complications?(Required) Yes No Any related surgeries or procedures for this disorder?(Required) Yes No Date(s):(Required) Do you have any limitations?(Required) Yes No Additional Comments: MEDICAL CONDITIONS:Digestive / Urinary / EndocrineTo the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?(Required) Bowel or Bladder Disease / Disorder Colitis Crohn's Disease Diabetes Endocrine or Pituitary Disorder Gastrointestinal Disorder Genitourinary Disorder Neurogenic Bladder Kidney Failure or received Dialysis Kidney or Liver Disease / Disorder Thyroid Disease NONE OF THE ABOVE BOWEL OR BLADDER DISEASE / DISORDER: When were you diagnosed?(Required) Any history of surgery?(Required) Yes No How is it treated?(Required) Any complications or hospitalizations?(Required) Is the condition resolved?(Required) Yes No COLITIS: When were you diagnosed?(Required) Have you been fully recovered for at least 6 months?(Required) Yes No Do you have ulcerative colitis?(Required) Yes No How many flares have you had in the last 2 years?(Required) CROHN'S DISEASE: When were you diagnosed?(Required) Date of last episode:(Required) How many flares have you had in the last 2 years?(Required) Have you had surgery (colostomy, colectomy)?(Required) Yes No Date(s):(Required) Do you experience problems with continence?(Required) Yes No DIABETES: When were you diagnosed?(Required) Type 1 or Type 2 diabetes?(Required) Type 1 Type 2 Any complications such as neuropathy, retinopathy, kidney disease?(Required) Yes No Dates and results of your last 2 A1C readings:(Required) ENDOCRINE OR PITUITARY DISORDER: When were you diagnosed?(Required) Name of condition you've been diagnosed with:(Required) Is the condition stable, non-progressive?(Required) Yes No Any surgery completed or anticipated?(Required) Yes No GASTROINTESTINAL DISORDER: When were you diagnosed?(Required) Name of the disorder?(Required) What symptoms do you experience?(Required) When was the last time you experienced symptoms?(Required) Any related surgeries or procedures for this disorder?(Required) Yes No Date(s):(Required) GENITOURINARY DISORDER: When were you diagnosed?(Required) Name of the disorder?(Required) What symptoms do you experience?(Required) When was the last time you experienced symptoms?(Required) Any related surgeries or procedures for this disorder?(Required) Yes No Date(s):(Required) KIDNEY FAILURE OR RECEIVED DIALYSIS: When was the episode of kidney failure?(Required) What was the underlying cause?(Required) Have you received dialysis?(Required) Yes No When did it end?(Required) Any ongoing complications?(Required) Yes No Provide details:(Required) Are your kidney function lab results normal now?(Required) Yes No Are both of your kidneys functioning normally now?(Required) Yes No KIDNEY OR LIVER DISEASE / DISORDER: When was it diagnosed?(Required) Name of the disease or disorder?(Required) Is the condition considered to be mild, moderate or severe?(Required) Mild Moderate Severe Any related surgeries or procedures for the disorder?(Required) Yes No Date(s):(Required) Are your lab results normal?(Required) Yes No Does the condition cause any limitations?(Required) Yes No NEUROGENIC BLADDER: When were you diagnosed?(Required) Is it considered congenital?(Required) Yes No Do they know the cause?(Required) Yes No Any related surgeries or procedures for the disorder?(Required) Yes No Date(s):(Required) Any complications?(Required) Yes No Do you have any limitations?(Required) Yes No THYROID DISEASE: When were you diagnosed?(Required) Name of the disorder?(Required) Is the condition stable and well controlled?(Required) Yes No Any surgery to treat the condition?(Required) Yes No Date(s):(Required) Additional comments: MEDICAL CONDITIONS:MusculoskeletalTo the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?(Required) Amputation Arthritis Back, Bone, Joint Disorder / Broken Bones Difficulty Walking Disabling Back or Spine Condition Falls or Injuries due to Falls or Imbalance Joint Replacement Surgery Muscular Dystrophy Musculoskeletal Disorder Osteoporosis Paralysis Post-Polio Syndrome Spinal Cord Injury NONE OF THE ABOVE AMPUTATION: Date of amputation:(Required) Was the amputation due to trauma or disease?(Required) Trauma Disease Location of amputation:(Required) Do you have any physical limitations?(Required) Yes No ARTHRITIS: When were you diagnosed?(Required) Is it classified as mild, moderate or severe?(Required) Mild Moderate Severe Have you required physical therapy or injections?(Required) Yes No Date(s):(Required) Has surgery been performed or recommended?(Required) Yes No Date(s):(Required) Do you have any physical limitations?(Required) Yes No BACK, BONE, JOINT DISORDER / BROKEN BONES: When were you diagnosed?(Required) What's the condition you've been diagnosed with?(Required) What joints are affected?(Required) Have you required physical therapy or injections?(Required) Yes No Date(s):(Required) Has surgery been performed or recommended?(Required) Yes No Date(s):(Required) DIFFICULTY WALKING: Provide details.DISABLING BACK OR SPINE CONDITIONS: When were you diagnosed?(Required) Name of condition you've been diagnosed with:(Required) What limitations are you experiencing?(Required) Any pending surgery, therapy or injections?(Required) Yes No Date(s):(Required) Any history of surgery, physical therapy, injections?(Required) Yes No Date(s):(Required) FALLS OR INJURIES DUE TO FALLS OR IMBALANCE: Date(s) of fall or injury:(Required) What caused the fall or injury?(Required) JOINT REPLACEMENT SURGERY: When was the surgery?(Required) What joint(s) were replaced?(Required) When was your last physical therapy session?(Required) When did you last use pain medication?(Required) Are you fully recovered with no limitations?(Required) Yes No Any complications or residuals from the surgery?(Required) Yes No MUSCULOSKELETAL DISORDER: When were you diagnosed?(Required) Name of the disorder?(Required) What areas of the body are affected?(Required) Any history of therapy, injections or surgery?(Required) Yes No Date(s):(Required) Are you fully recovered with no limitations?(Required) Yes No OSTEOPOROSIS: When were you diagnosed?(Required) Date of your last bone density test:(Required) Test results:(Required) Do you have a history of fractures or falls?(Required) Yes No Provide details:(Required) Any limitations?(Required) Yes No Provide details:(Required) PARALYSIS: When did this occur?(Required) What area of the body is affected?(Required) Was the paralysis due to disease or trauma/accident?(Required) Disease Trauma / Accident Any limitations?(Required) Yes No Provide details:(Required) POST-POLIO SYNDROME: Has the condition been stable for 12 months?(Required) Yes No Do you have progressive weakness or fatigue?(Required) Yes No Any limitations?(Required) Yes No Provide details:(Required) SPINAL CORD INJURY: When were you diagnosed?(Required) How did the injury occur?(Required) Any history of surgery, physical therapy, injections?(Required) Yes No Date(s):(Required) Are you currently undergoing treatment?(Required) Yes No Provide details:(Required) Do you have any limitations?(Required) Yes No Provide details:(Required) Additional comments: MEDICAL CONDITIONS:CancerTo the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?(Required) Cancer Leukemia Lymphoma Multiple Myeloma Hodgkin's Disease NONE OF THE ABOVE CANCER: When were you diagnosed?(Required) What type of cancer/location?(Required) Stage:(Required) Any lymph node involvement?(Required) Yes No How many?(Required) Type of treatment:(Required) When did treatment begin?(Required) When did treatment end?(Required) Any recurrence of the cancer?(Required) Yes No Did the cancer metastasize/spread?(Required) Yes No HODGKIN'S DISEASE: When were you diagnosed?(Required) What stage was it classified as?(Required) How was it treated?(Required) Date of last treatment:(Required) How long has it been in remission?(Required) Any recurrence?(Required) Yes No LEUKEMIA: When were you diagnosed?(Required) Name/type of leukemia:(Required) What stage was it classified as?(Required) How was it treated?(Required) Date of last treatment:(Required) How long has it been in remission?(Required) Any recurrence?(Required) Yes No LYMPHOMA - When were you diagnosed?(Required) Type of lymphoma:(Required) How was it treated?(Required) Date of last treatment:(Required) How long has it been in remission?(Required) Any recurrence?(Required) Yes No MULTIPLE MYELOMA: When were you diagnosed?(Required) What stage was it classified as?(Required) How was it treated?(Required) Date of last treatment:(Required) How long has it been in remission?(Required) Any recurrence?(Required) Yes No Any history of blood clots?(Required) Yes No Any fractures due to the multiple myeloma?(Required) Yes No Additional comments: MEDICAL CONDITIONS:Autoimmune / InflammatoryTo the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?(Required) AIDS / ARC Cirrhosis Fibromyalgia Hepatitis Immune System Disease / Disorder Lupus Multiple Sclerosis (MS) Myasthenia Gravis Polymyositis Rheumatoid Arthritis Sarcoidosis Scleroderma / CREST Syndrome NONE OF THE ABOVE FIBROMYALGIA: When were you diagnosed?(Required) Are you currently experiencing any symptoms?(Required) Yes No Provide details:(Required) Do you have any physical limitations?(Required) Yes No Provide details:(Required) Is the condition stable, non-progressive?(Required) Yes No HEPATITIS: When were you diagnosed?(Required) Type of hepatitis diagnosed:(Required) How was it treated?(Required) Is the virus now undetectable?(Required) Yes No When were you cleared of the virus?(Required) Are your liver function lab results normal?(Required) Yes No IMMUNE SYSTEM DISEASE / DISORDER: When were you diagnosed?(Required) Name of the disorder?(Required) Any related surgeries or procedures for the disorder?(Required) Yes No Date(s):(Required) How was it treated?(Required) What symptoms do you experience?(Required) When was the last time you experienced symptoms?(Required) Does the condition cause any limitations?(Required) Yes No Provide details:(Required) LUPUS: When were you diagnosed?(Required) Is the lupus considered discoid or systemic?(Required) Discoid Systemic Any internal organ involvement?(Required) Yes No Is it in remission?(Required) Yes No For how long?(Required) Any current symptoms?(Required) Yes No Provide details:(Required) MYASTHENIA GRAVIS: When were you diagnosed?(Required) Is the condition ocular or generalized?(Required) Ocular Generalized Are you experiencing symptoms?(Required) Yes No Provide details:(Required) Has the condition been stable for the last 12 months?(Required) Yes No Do you have any limitations?(Required) Yes No Provide details:(Required) POLYMYOSITIS: When were you diagnosed?(Required) Are you currently undergoing treatment?(Required) Yes No When was the last time you experienced symptoms?(Required) Do you have any limitations?(Required) Yes No Provide details:(Required) RHEUMATOID ARTHRITIS: When were you diagnosed?(Required) What joints are affected?(Required) When was your last flare up?(Required) Any history of joint replacements, physical therapy, injections?(Required) Yes No Date(s) and details:(Required) Do you have any limitations?(Required) Yes No Provide details:(Required) Is the condition stable and well controlled?(Required) Yes No SARCOIDOSIS: When were you diagnosed?(Required) What areas of the body are affected?(Required) If your lungs are involved, have you had pulmonary testing done? Yes No Are you currently undergoing treatment?(Required) Yes No Provide details:(Required) Are you currently experiencing symptoms?(Required) Yes No Provide details:(Required) Are you in remission?(Required) Yes No For how long?(Required) SCLERODERMA / CREST SYNDROME: When were you diagnosed?(Required) Is it diagnosed as discoid or systemic?(Required) Discoid Systemic What areas of the body are affected?(Required) Any joint or organ involvement?(Required) Yes No How is it treated?(Required) Any limitations?(Required) Yes No Provide details:(Required) Additional comments: MEDICAL CONDITIONS:OtherTo the best of your knowledge and belief, do you have, or have you ever received any advice, treatment, consultations or diagnosis from a physician or health care provider for any of the following conditions?(Required) Alcohol or Drug Abuse / Addiction Asthma / COPD / Emphysema Cystic Fibrosis Ear or Eye Disorder Organ Transplant Skin Ulcers Sleep Apnea Unexplained / Unplanned Weight Loss or Gain Weakness or Fatigue NONE OF THE ABOVE ALCOHOL OR DRUG ABUSE / ADDICTION: How long have you been abstinent?(Required) Have you ever had a relapse?(Required) Yes No Date(s):(Required) Have you ever received treatment in a facility?(Required) Yes No Date(s):(Required) Do you currently attend a support group?(Required) Yes No ASTHMA / COPD / EMPHYSEMA: When were you diagnosed?(Required) Is it classified as mild, moderate or severe?(Required) Mild Moderate Severe When was your last exacerbation?(Required) Did it require hospital or ER visit?(Required) Yes No Date(s) and details:(Required) Have pulmonary function tests been performed?(Required) Yes No Date/Results (FEV1 and FEV%):(Required) Are your activities limited as a result of the condition?(Required) Yes No Provide details:(Required) EAR OR EYE DISORDER: When were you diagnosed?(Required) Name of condition you've been diagnosed with:(Required) Is the condition stable, non-progressive?(Required) Yes No Provide details:(Required) Any surgery completed or anticipated?(Required) Yes No Provide details:(Required) ORGAN TRANSPLANT: When was the surgery?(Required) What organ required the transplant?(Required) What was the underlying cause for needing the transplant?(Required) Have you had any complications or issues of rejection?(Required) Yes No Provide details:(Required) SKIN ULCERS: When were you diagnosed?(Required) Is it arterial or venous?(Required) Arterial Venous Date(s) of occurrence(s):(Required) Any history of gangrene?(Required) Yes No Any recurrence?(Required) Yes No Are you fully recovered with no limitations?(Required) Yes No Provide details:(Required) SLEEP APNEA: When were you diagnosed?(Required) What's the diagnosed severity of your sleep apnea?(Required) Mild Moderate Severe Do you use a CPAP machine?(Required) Yes No Are you compliant with the CPAP and use it nightly?(Required) Yes No How long have you been using the CPAP machine?(Required) UNEXPLAINED / UNPLANNED WEIGHT LOSS/GAIN(Required) Over the last 12 months how has your weight changed?(Required) Can you associate it to anything in particular?(Required) Yes No Provide details:(Required) Has testing been done to determine an underlying cause?(Required) Yes No Provide details:(Required) WEAKNESS OR FATIGUE: When did you first start experiencing these symptoms?(Required) Has testing been done to determine an underlying cause?(Required) Yes No Provide details:(Required) Does it affect your everyday functioning?(Required) Yes No Provide details:(Required) Has the condition resolved?(Required) Yes No Additional comments:OTHER CONDITION(S) NOT LISTED:Provide the name of any other medical condition that has not been previously mentioned as well as any details such as diagnosis date, treatment, severity, and resolution.
