LTC Informal Health Pre-Screen Inquiry

Will your spouse / partner be included in insurance plan, please indicate yes/no.
Any gain or loss of 15 pounds in past year.
Any gain or loss of 15 pounds in past year.
Please list all generic medications with dose, date prescribed, and reason/condition for the primary subscriber:
Please list all generic medications with dose, date prescribed, and reason/condition for the primary subscriber:
Check all that apply and provide details in section below.
Check all that apply and provide details in section below.
Please provide details to items checked above including the condition, the date of treatment and if it is current or date of recovery.
Please provide details to items checked above including the condition, the date of treatment and if it is current or date of recovery.

After submitting, we will connect with you for a confidential conversation about your health status.

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