Long-Term Care Insurance Health Prescreen Form

Let's see what LTC insurance options are available to you. The first step is to gather a snapshot of your health history and lifestyle. Your coverage options and rates will vary based on the details you provide. Please be honest - there's not judgment here, just data! If you're on any medications, be sure to have them handy when completing this form, as you'll need to provide details.

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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 INFO

Name(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Are you a U.S. citizen?(Required)

Yes

Are you a permanent resident?(Required)

Yes

Marital Status(Required)

Married

Live with partner

Single

Will your spouse/partner be applying for coverage?(Required)

Yes

Will your spouse/partner be applying for coverage?(Required)

Yes

Do you have a specific max budget for LTC insurance?(Required)

Yes

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

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

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

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

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

Please provide details.(Required)

HEALTH INFO

Height(Required)

Weight (at doctor's office)(Required)

Have you had any weight loss in the last 12 months?(Required)

Yes

Amount of weight loss(Required)

Reason for weight loss(Required)

Do you or have you ever used tobacco products or marijuana?(Required)

Yes

Are you a current user?(Required)

Yes

What form of tobacco or marijuana?(Required)

When did you last use tobacco or marijuana?(Required)

Have you tested positive for COVID?(Required)

Yes

Approximate Date of Positive COVID Test(Required)

Were you hospitalized?(Required)

Yes

Any residual symptoms from COVID?(Required)

Yes

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

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

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

Do you have (for your use) a handicap parking sticker or handicap license plate?(Required)

Yes

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

Provide details on medications - IF MORE THAN ONE MED, CLICK THE + ON THE RIGHT TO ADD ANOTHER(Required)

Medication Name

Purpose

Date First Prescribed

Frequency

Dosage

Date of Last Dosage Change

Type N/A if not applicable.

In the past 3 years, were you prescribed a medication but didn't take it?(Required)

Yes

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

Provide details:(Required)

Are there any pending test results which you have not yet received?(Required)

Yes

Provide details:(Required)

Have you had any recent lab work or testing that has back abnormal or shown elevated PSA levels?(Required)

Yes

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

Provide details:(Required)

Have you ever told your doctor you're experiencing memory decline or loss?(Required)

Yes

Provide details:(Required)

Has your biological mother, father, sibling or grandparent been diagnosed with Alzheimer's, Dementia or another cognitive impairment?(Required)

Yes

Unknown

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 System

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?(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

Date(s):(Required)

Does the condition limit any of your regular activities?(Required)

Yes

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

Is there brain atrophy / volume loss?(Required)

Yes

Any findings of lacunar infarct(s)?(Required)

Yes

CEREBROVASCULAR ACCIDENT / STROKE: Date of accident / stroke:(Required)

Was it a single event or multiple occurrences?(Required)

Yes

Any residual impairment (weakness, slurred speech, mobility problems, etc)?(Required)

Yes

Has there been a 100% recovery?(Required)

Yes

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

Date(s):(Required)

Does the condition limit any of your regular activities?(Required)

Yes

DIZZINESS / VERTIGO: When were you diagnosed?(Required)

When was your last dizziness/vertigo episode?(Required)

How often do you experience episodes?(Required)

Has the condition been worked up and ruled benign?(Required)

Yes

When and what workup and was completed to say it was benign? CT scan? Neurologist visit?(Required)

Were you taught the Epley maneuver and do you practice it?(Required)

Yes

Were there any associated falls?(Required)

Yes

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

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

Do you have any limitations?(Required)

Yes

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

Has the condition been stable for 12 months?(Required)

Yes

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

Has the tremor been fully evaluated?(Required)

Yes

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

Additional comments:

MEDICAL CONDITIONS:

Cardiovascular / Circulatory

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

Have your labs been normal?(Required)

Yes

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

Date(s):(Required)

Are you currently experiencing any cardiac symptoms?(Required)

Yes

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

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

Do you know your last ejection fraction reading?(Required)

Yes

CAROTID ARTERY DISEASE: When were you diagnosed?(Required)

Any surgery?(Required)

Yes

Date(s):(Required)

Is it resolved?(Required)

Yes

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

CORONARY ARTERY DISEASE: When were you diagnosed?(Required)

Any surgical procedures?(Required)

Yes

Date(s):(Required)

Do you experience any symptoms such as shortness of breath, chest pain, fatigue?(Required)

Yes

Do you go for regular cardiac follow-up visits?(Required)

Yes

Date of last cardiac testing:(Required)

Were results normal?(Required)

Yes

DEFIBRILLATOR: Date of defibrillator placement:(Required)

Has the defibrillator ever fired?(Required)

Yes

HEART ATTACK: Date of heart attack(s):(Required)

Any related surgeries or procedures as a result of the heart attack(s):(Required)

Yes

Date(s) and details:(Required)

Do you currently experience any chest pain or discomfort?(Required)

Yes

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

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

Any related surgeries or procedures for this disorder?(Required)

Yes

Date(s):(Required)

Do you have any limitations?(Required)

Yes

Additional Comments:

MEDICAL CONDITIONS:

Digestive / Urinary / Endocrine

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: Name of disease or disorder?(Required)

BOWEL OR BLADDER DISEASE / DISORDER: When were you diagnosed?(Required)

Any history of surgery?(Required)

Yes

How is it treated?(Required)

Any complications or hospitalizations?(Required)

Is the condition resolved?(Required)

Yes

COLITIS: When were you diagnosed?(Required)

Have you been fully recovered for at least 6 months?(Required)

Yes

Do you have ulcerative colitis?(Required)

Yes

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

Date(s):(Required)

Do you experience problems with continence?(Required)

Yes

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

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

Any surgery completed or anticipated?(Required)

Yes

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

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

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

When did it end?(Required)

Any ongoing complications?(Required)

Yes

Provide details:(Required)

Are your kidney function lab results normal now?(Required)

Yes

Are both of your kidneys functioning normally now?(Required)

Yes

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

Date(s):(Required)

Are your lab results normal?(Required)

Yes

Does the condition cause any limitations?(Required)

Yes

NEUROGENIC BLADDER: When were you diagnosed?(Required)

Is it considered congenital?(Required)

Yes

Do they know the cause?(Required)

Yes

Any related surgeries or procedures for the disorder?(Required)

Yes

Date(s):(Required)

Any complications?(Required)

Yes

Do you have any limitations?(Required)

Yes

THYROID DISEASE: When were you diagnosed?(Required)

Name of the disorder?(Required)

Is the condition stable and well controlled?(Required)

Yes

Any surgery to treat the condition?(Required)

Yes

Date(s):(Required)

Additional comments:

MEDICAL CONDITIONS:

Musculoskeletal

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

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

Date(s):(Required)

Has surgery been performed or recommended?(Required)

Yes

Date(s):(Required)

Do you have any physical limitations?(Required)

Yes

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

Date(s):(Required)

Has surgery been performed or recommended?(Required)

Yes

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

Date(s):(Required)

Any history of surgery, physical therapy, injections?(Required)

Yes

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

Any complications or residuals from the surgery?(Required)

Yes

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

Date(s):(Required)

Are you fully recovered with no limitations?(Required)

Yes

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

Provide details:(Required)

Any limitations?(Required)

Yes

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

Provide details:(Required)

POST-POLIO SYNDROME: Has the condition been stable for 12 months?(Required)

Yes

Do you have progressive weakness or fatigue?(Required)

Yes

Any limitations?(Required)

Yes

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

Date(s):(Required)

Are you currently undergoing treatment?(Required)

Yes

Provide details:(Required)

Do you have any limitations?(Required)

Yes

Provide details:(Required)

Additional comments:

MEDICAL CONDITIONS:

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

How many?(Required)

Type of treatment:(Required)

When did treatment begin?(Required)

When did treatment end?(Required)

Any recurrence of the cancer?(Required)

Yes

Did the cancer metastasize/spread?(Required)

Yes

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

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

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

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

Any history of blood clots?(Required)

Yes

Any fractures due to the multiple myeloma?(Required)

Yes

Additional comments:

MEDICAL CONDITIONS:

Autoimmune / Inflammatory

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

Provide details:(Required)

Do you have any physical limitations?(Required)

Yes

Provide details:(Required)

Is the condition stable, non-progressive?(Required)

Yes

HEPATITIS: When were you diagnosed?(Required)

Type of hepatitis diagnosed:(Required)

How was it treated?(Required)

Is the virus now undetectable?(Required)

Yes

When were you cleared of the virus?(Required)

Are your liver function lab results normal?(Required)

Yes

IMMUNE SYSTEM DISEASE / DISORDER: When were you diagnosed?(Required)

Name of the disorder?(Required)

Any related surgeries or procedures for the disorder?(Required)

Yes

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

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

Is it in remission?(Required)

Yes

For how long?(Required)

Any current symptoms?(Required)

Yes

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

Provide details:(Required)

Has the condition been stable for the last 12 months?(Required)

Yes

Do you have any limitations?(Required)

Yes

Provide details:(Required)

POLYMYOSITIS: When were you diagnosed?(Required)

Are you currently undergoing treatment?(Required)

Yes

When was the last time you experienced symptoms?(Required)

Do you have any limitations?(Required)

Yes

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

Date(s) and details:(Required)

Do you have any limitations?(Required)

Yes

Provide details:(Required)

Is the condition stable and well controlled?(Required)

Yes

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

Are you currently undergoing treatment?(Required)

Yes

Provide details:(Required)

Are you currently experiencing symptoms?(Required)

Yes

Provide details:(Required)

Are you in remission?(Required)

Yes

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

How is it treated?(Required)

Any limitations?(Required)

Yes

Provide details:(Required)

Additional comments:

MEDICAL CONDITIONS:

Other

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

Date(s):(Required)

Have you ever received treatment in a facility?(Required)

Yes

Date(s):(Required)

Do you currently attend a support group?(Required)

Yes

ASTHMA / COPD / EMPHYSEMA: When were you diagnosed?(Required)

Which one?(Required)

Asthma

COPD

Emphysema

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

Date(s) and details:(Required)

Have pulmonary function tests been performed?(Required)

Yes

Date/Results (FEV1 and FVC):(Required)

Are your activities limited as a result of the condition?(Required)

Yes

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

Provide details:(Required)

Any surgery completed or anticipated?(Required)

Yes

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

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

Any recurrence?(Required)

Yes

Are you fully recovered with no limitations?(Required)

Yes

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

Are you compliant with the CPAP and use it nightly?(Required)

Yes

How long have you been using the CPAP machine?(Required)

What's your AHI (apnea-hypopnea index)?(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

Provide details:(Required)

Has testing been done to determine an underlying cause?(Required)

Yes

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

Provide details:(Required)

Does it affect your everyday functioning?(Required)

Yes

Provide details:(Required)

Has the condition resolved?(Required)

Yes

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.