Long-Term Care Insurance Pre-qualification Questionnaire
|
1. Please list all prescription medications and the specific reasons they are being taken. If possible, indicate the dosage, frequency of use, and the dates they were first prescribed. |
|
|
2. When was your last visit to a physician? What was the reason? When was your last physical exam? What were the results of the exam (normal)? |
|
|
3. Has surgery been recommended and not yet performed? Has surgery been performed in the past and for what reason? |
|
|
4. Have you been hospitalized within the past 5 years? If the answer is yes, please list the reason(s) and date(s). Also indicate the date of the last treatment. |
|
|
5. Do you use a cane, walker, or wheelchair? If so, please indicate the device used and frequency. |
|
|
6. Have you used tobacco products in the past 5 years? What kind? |
|
|
7. What is your height and weight? Has there been a significant increase or decrease in weight within the past year? If yes, state the reason. |
|
|
8. Have you ever been diagnosed with cancer? If yes, please indicate the stage or grade of the cancer and the date of the last treatment. |
|
|
10. Please list any other medical conditions or concerns: |
|
