Trial Scan Questionnaire for
Long Term Care
  Click Here for a printable version
 
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Client Information

Last Name    First    Male     Female

 Date of birth:     / / or Age   State of Residence:

 Height: ft in. Weight: lbs Smoker: Yes No

 Premium Commitment: $ Daily Benefit Amount: $

 Waiting Period:   30 Days  60 Days   90 Days   180 Days

 Days Benefit Period:   1 yr  2 yrs    3 yrs   4 yrs   5 yrs   6 yrs

 Benefit Type: Comprehensive Home Care Facility Care


Medical Profile
Yes
No Has the applicant been medically diagnosed as having any of the following conditions?
    Acquired Immune Deficiency Syndrome (AIDS) ALS (Lou Gehrig's Disease) Alzheimer's Disease
    HIV Positive Chronic Memory Loss Senilty/Dementia
    Organic Brain Syndrome Muscular Dystrophy Huntington's Chorea
    Down's Syndrome Cebebral Palsey Psychosis/Schizophrenia

If any of the above are answered "YES," THE CLIENT WILL NOT QUALIFY -- Otherwise, please continue.
 

Does your client currenly need the assistance or supervision of another person in performing any of the following activities (if yes, please check all that apply)

    Bathing; Dressing; Eating
    Toileting; Bowel/Bladder Control
    Moving in/out of bed or chair;  

Yes     No

Within the past five (5) years has your client; received medical advice or treatment taken any medications, diagnosed, been confined to a convalescent care facility, hospital, or nursing facility, or professional for any of the following conditions; (if "YES," check any that apply)
Stroke; Transient lschemic Attack (TIA); Paralysis;
Cancer, Leukemia; Lymphoma; Hodgkin's Disease;
Angioplasty; Heart Attack: Heart Surgeny; High Blood Pressure;
Congesstive Heart Failure (CHF); Disabling Back or Spine Injury?
 

Yes     No
Emphysema; Fainting Spells; Shortness of Breath:
Blacking Out: Injury due to Falls or Imbalance?  
 

Yes     No
Depression; Mental Illness; Brain Disorder;    
Alcoholism; Drug Addiction?      
 

Yes     No
Epilepsy; Convulsions; Seizures: Tremor;
Diabete: Skin Ulcers;    
 

Yes     No
Multiple Sclerosis; Osteoporosis;      
other conditions causing Crippling or Limited Motion      
 

 

 Yes     No
During the past three (3) years has the applicant:  
a) Been medically advised to have surgery which has not been performed?   Yes     No
b) Consulted with or been treated by a health professional for any reason not previously stated
    (excluding eye doctors, podiatrists,chiropractors, and dentists)?  

Yes     No

c) Received home care? been medically advised to enter a nursing home;
    used an adult day care facility? been confined to a hospital or any other health care facility?

DETAILS FOR "YES" ANSWER TO ANY PART OF QUESTION1, 2 AND 3

Describe Sickness/Injury and Treatment (if surgery performed - state type)
 Dates of Symptoms
and/or Treatment 		Degree of Recovery
(+addiional notes) 		Medication(s) Taken
From:
To:    

From:
To:    

From:
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From:
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From:
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From:
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From:
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Agent Information - How do we reach you?

Last Name:   First:

Phone:  Fax:

Email: