Step 1 of 3 33% Name Street Address City State Zip PhoneDate of Birth MM slash DD slash YYYY Email Gender Male Female Are you married? Yes No Are you a U.S. Citizen? Yes No HeightWeightHave you had any weight loss in the last 12 months? Yes No If yes, how much and why? Do you or have you ever used tobacco products? Yes No Are you a current user? Yes No If not, when did you last use? 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 with long-term care coverage)? 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? Yes No 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? Yes No Have you ever been declined, rated or denied reinstatement for long-term care insurance? Yes No If yes, by what company, when, and why? Do you currently use any of the following? Wheelchair Walker Nebulizer Electric Scooter Quad Cane Oxygen Hospital Bed Respirator Kidney Dialysis Crutches Stair lift Have you been confined to, or been advised to have, or used any of the following: Residential Care Assisted Living or Adult Day Care Facility Services Nursing Home or Home Health Care Services Long-Term Care Facility Physical Therapy Occupational Therapy Speech Therapy Have you been medically advised to enter or been confined to a hospital or other health care facility? Yes No Do you require assistance or supervision of another person or a device of any kind for any of the following? Bathing, toileting, dressing, eating, walking, medication management, getting in and out of a chair or bed, or control of your bowel or bladder? Yes No Do you require assistance with shopping, using transportation or housekeeping/cooking? Yes No Do you have diabetes? Yes No Date of diagnosis? MM slash DD slash YYYY What was your last A1C reading? If you are currently using insulin, how many units per day? Do you have diabetes in combination with any of the following (please check all that apply): Peripheral Neuropathy Numbness Tingling or decreased sensation in your feet Retinopathy or history of stroke, mini stroke Heart Disease or Circulatory/Vascular Disease Have you ever been diagnosed with cancer? Yes No Type (note if metastatic cancer) and stage Treatment and date of last treatment If prostate cancer, provide PSA levels Have you ever been diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Emphysema or Chronic Bronchitis or Asthma? Yes No Do you have congestive heart failure in combination with any of the following (please check all that apply): Heart Attack Angina Emphysema/COPD Angioplasty Heart Surgery Asthma Chronic Bronchitis Have you ever been diagnosed or treated by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC), any other sickness or condition derived from such infection, or tested positive for HIV or exposure to the HIV infection? Yes No Have you ever talked to your doctor about memory loss? Is memory loss noted in your medical records? Yes No 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? 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? Yes No Have you had any dosage changes in the last 12 months? Yes No If yes, please provide medication name, dosage, date change, and reason for change: Are you taking any kind of narcotic medication? Yes No If yes, what, how much, how often, and reason for taking? Have you received inpatient or outpatient treatment at a hospital, surgical center or rehabilitation facility in the past 5 years? Yes No If yes, provide details 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? Yes No If yes, provide details Are there any pending test results which you have not yet received? Yes No If yes, provide details Have you had any recent lab work or testing that has come back abnormal, or shown elevated PSA levels? Yes No If yes, provide details Have you been seen by a physician, health care provider or any specialist more than 3 times in the past 12 months? Yes No If yes, provide details Within the past 3 years, have you consulted with or been treated by a licensed health care provider, other than your primary care doctor, for any reason, excluding eye doctors, podiatrists and dentists? Yes No If yes, provide details When was your last physical and full lab work completed? Do you have (for your use) a handicap parking sticker or handicap license plate? Yes No Do you currently work? Yes No If yes, how many hours per week? Do you perform volunteer work? Yes No If yes, approximately how many hours per week? Do you have any hobbies or interests, or participate in any outside activities on a regular basis? Yes No If yes, approximately how many hours per week? Do you drive an automobile? Yes No Do you live in some form of a residential retirement community? Yes No If yes, list the services that are received: Is your mother living? Yes No What is her current age or her age at death? Check if your mother has/had any of the following and age of onset for each: Diabetes Coronary Artery Disease/Vascular Disease Alzheimer’s/Dementia Alzheimer’s/Dementia Coronary Artery Disease/Vascular Disease Alzheimer’s/Dementia Is your father living? Yes No What is his current age or his age at death? Check if your father has/had any of the following and age of onset for each: Diabetes Coronary Artery Disease/Vascular Disease Alzheimer’s/Dementia Alzheimer’s/Dementia Coronary Artery Disease/Vascular Disease Alzheimer’s/Dementia 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? Yes No Has there been a diagnosis or treatment by a health care professional for Alzheimer’s Disease, Dementia or Huntingtons Disease in the your birth mother, birth father or birth siblings? Yes No To 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? Please check any that apply and provide details below.Alcohol or Drug Abuse/Addiction Yes No Difficulty Walking Yes No Musculoskeletal Disorders Yes No Alzheimer’s Disease Yes No Depression or Mental Disorder/Illness Yes No Myasthenia Gravis Yes No Amputation Yes No Dizziness/Fainting Spells/Blacking Out Yes No Neurological Disease/Disorder Yes No Amyotrophic Lateral Sclerosis (ALS) Yes No Ear or Eye Disorders Yes No Organ Transplant Yes No Anemia or Blood Disease/Disorder Yes No Endocrine or Pituitary Disorders Yes No Organic Brain Syndrome Yes No Aneurysm Yes No Epilepsy or Tremors Yes No Osteoporosis Yes No Angina or Atrial Fibrillation Yes No Fibromyalgia Yes No Paralysis Yes No Angioplasty or Heart Surgery Yes No Falls or Injuries due to Falls or Imbalance Yes No Parkinson’s Disease Yes No Arthritis Yes No Gastrointestinal Disorders Yes No Peripheral Vasculary Disease Yes No Back, Bone, Joint Disorder, Broken Bones Yes No Genitourinary Disorders Yes No Post-Polio Syndrome Yes No Balance Disorder Yes No Heart Attack Yes No Polymyositis Yes No Blood Disease/Disorder Yes No Hodgkin’s Disease Yes No Psychosis Yes No Brain Disorder Yes No Huntington’s Chorea Yes No Respiratory Disease/Disorders Yes No Bowel or Bladder Disease/Disorder Yes No Heart Disease/Disorder or High Blood Pressure Yes No Rheumatoid Arthritis Yes No Bypass Surgery Yes No Immune System Disease/Disorder Yes No Sarcoidosis Yes No Cancer Yes No Joint Replacement Surgery Yes No Schizophrenia Yes No Cardiomyopathy Yes No Kidney Failure or received Dialysis Yes No Scleroderma Yes No Carotid or other Arterial Surgery Yes No Kidney or Liver Disease/Disorder Yes No Seizures Yes No Cerebrovascular Accident Yes No Leukemia Yes No Senility Yes No Chronic Hepatitis Yes No Lupus/Systemic Lupus Yes No Skin Ulcers Yes No Circulatory Disease/Disorder Yes No Lymph Node Disease/Disorder Yes No Spinal Cord Injury Yes No Cirrhosis Yes No Macular Degeneration Yes No Thyroid Disease Yes No Congestive Heart Failure Yes No Mental or Cognitive Disorder Yes No Tuberculosis Yes No Convulsions Yes No Mental Retardation Yes No Unexplained/Unplanned Weight Loss/Gain Yes No CREST Syndrome Yes No Multiple Myeloma Yes No Ulcerative Colitis Yes No Cystic Fibrosis Yes No Memory Loss or Frequent/Persistent Forgetfulness Yes No Vision Disorder Yes No Dementia Yes No Multiple Sclerosis (MS) Yes No Weakness or Fatigue Yes No Diabetes Yes No Muscular Dystrophy Yes No Any Other Conditions Causing Crippling/Limited Motion/Requiring Adaptive Devices Yes No Disabling Back or Spine Condition Yes No Mini stroke or Transient Ischemic Attack (TIA) Yes No Provide details to YES answersProvide details on medicationsMedicationCondition Treated & Date of DiagnosisDosage & FrequencyName of Physician Add Remove
