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LTC Health Screening Questionare

Agent Information

1. Agent Name
2. Tel. No.
3. Client Name
4. State -- Select -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
5. Zip Code
6. Date of Birth
7. Height -- Feet -- 1' 2' 3' 4' 5' 6' 7' 8' 9' 10' -- Width -- 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"
8. Are You Married?:

   Yes No
9. Have you used tobacco products in the past 12 months?:

   Yes No Type / How Much?
10. Were you ever declined for long-term care insurance?:

    Yes No
11. Are you receiving Social Security Disability Income?:

    Yes No

1. List all prescription medications taken over the past 12 months:
2. Medication Amount Reason Perscribed

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3. Medication Amount Reason Perscribed

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4. Medication Amount Reason Perscribed

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5. Medication Amount Reason Perscribed

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6. Medication Amount Reason Perscribed

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1. Do you use:
2. Cane Crutches Braces Hospital Bed Lift Chair Walker Wheelchair Oxygen Kidney dialysis

1. Do you need assistance with:
2. Shopping Walking Using Transportation Housekeeping Cooking

1. Do you currently need the assistance or supervision of another person in performing any of the following activities?:
2. Moving in or out of Bed or Chair Bathing Dressing Toileting Eating Bowel/Bladder Control

1. Have you been referred for treatment or tests that have not yet been completed?:
2. Yes No

1. Do you currently need the assistance or supervision of another person in performing any of the following activities?:
2. Abnormal Brain Scan AIDS/HIV, Alcoholism ALS (Lou Gehrig’s) Alzheimer’s or Dementia Amputation Anemia Aneurysm Angioplasty or Bypass Anxiety Arthritis – What kind? Asthma or chronic bronchitis Bladder problems/Incontinence Blindness Blood disorders Brain disorders Bronchiectasis Cancer Chronic fatigue syndrome Cirrhosis of the liver Colitis, Crohn’s, or IBS Confusion/Memory Loss Carotid artery problem Congestive heart failure Coronary artery disease CREST syndrome Cystic fibrosis Depression Diabetes Type 1 or 2 Dizziness or falls Drug Abuse Embolisms Emphysema Epilepsy or Seizures Fainting or blackouts Fibromyalgia Fractures Heart Attack Heart arrhythmias Hepatitis - A, B, or C? High Blood Pressure Hodgkin’s disease Huntington’s chorea Immune disorders Joint Replacement Kidney Problems Liver disorders Lupus Macular degeneration Mental illness Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Neuropathy Organ Transplant Osteoporosis, osteopenia Parkinson’s Disease Peripheral Vascular Disease Polio or Post Polio Syndrome Prostate disorders Respiratory Disorders Rheumatoid arthritis Schizophrenia Scleroderma Sleep Apnea Spinal Stenosis Steroid Injection Stroke or TIA

1. List all prescription medications taken over the past 12 months:
2. Diagnosis Diagnosis Date Treatment / Prognosis

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3. Diagnosis Diagnosis Date Treatment / Prognosis

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4. Diagnosis Diagnosis Date Treatment / Prognosis

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5. Diagnosis Diagnosis Date Treatment / Prognosis

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6. Diagnosis Diagnosis Date Treatment / Prognosis

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7. Diagnosis Diagnosis Date Treatment / Prognosis

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8. Diagnosis Diagnosis Date Treatment / Prognosis

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9. Diagnosis Diagnosis Date Treatment / Prognosis

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