LTC Informal Health Pre-Screen Inquiry First Name(Required) First Name Enter your Preferred Contact Information (Phone or Email)(Required) Date of Birth(Required) MM slash DD slash YYYY State of Residence(Required) State Client Spouse / Partner Info(Required)Will your spouse / partner be included in insurance plan, please indicate yes/no. YES NO Date of Birth (Spouse / Partner)(Required) MM slash DD slash YYYY Height Weight Weight Gain / LossAny gain or loss of 15 pounds in past year. YES NO Height (Spouse/Partner) Weight (Spouse/Partner) Weight Gain / Loss (Spouse/Partner)Any gain or loss of 15 pounds in past year. YES NO Medications(Required)Please list all generic medications with dose, date prescribed, and reason/condition for the primary subscriber:Medications (Spouse/Partner)(Required)Please list all generic medications with dose, date prescribed, and reason/condition for the spouse / partner:Health Conditions(Required)Check all that apply and provide details in section below 1. Cancer history 2. Heart health- blood pressure, atrial fibrillation, coronary artery disease 3. Emotional health (anxiety, depression, sleep issues) 4. Blood disorders (anemia, hepatitis, HIV, etc.) 5. Stroke or TIA (mini stroke) 6. Breathing issues like Asthma or COPD 7. Sleep Apnea 8. Joint disorders and/or replacements (.ie hip, knee, shoulder, and neck or back) 9. Arthritis- osteoarthritis, rheumatoid, degenerative 10, Physical Therapy/ injection therapy for muscle/joint pain 11. Upcoming surgeries or procedures suggested or scheduled 12. Osteopina or Osteoporosis 13. Concerns of memory loss/forgetfulness or concussion history 14. Parents or Siblings with Alzheimer’s, Dementia or Senility 15. Huntington’s Chorea self or family members 16. Diabetes- type 1 or type 2 LIST A1C and insulin units Any diabetic complications- kidneys, eyes, skin, nerve pain 17. Smoking history 18. Surgeries past 10 years 19. Anything of concern that was not listed? 10. Covid Infection? 11. Medical Cannabis card or recreational use of cannabis 12. Gastro intestinal disorders 13. None of the above Health Conditions (Spouse/Partner)(Required)Check all that apply for your spouse / partner and provide details in section below 1. Cancer history 2. Heart health- blood pressure, atrial fibrillation, coronary artery disease 3. Emotional health (anxiety, depression, sleep issues) 4. Blood disorders (anemia, hepatitis, HIV, etc.) 5. Stroke or TIA (mini stroke) 6. Breathing issues like Asthma or COPD 7. Sleep Apnea 8. Joint disorders and/or replacements (.ie hip, knee, shoulder, and neck or back) 9. Arthritis- osteoarthritis, rheumatoid, degenerative 10, Physical Therapy/ injection therapy for muscle/joint pain 11. Upcoming surgeries or procedures suggested or scheduled 12. Osteopina or Osteoporosis 13. Concerns of memory loss/forgetfulness or concussion history 14. Parents or Siblings with Alzheimer’s, Dementia or Senility 15. Huntington’s Chorea self or family members 16. Diabetes- type 1 or type 2 LIST A1C and insulin units Any diabetic complications- kidneys, eyes, skin, nerve pain 17. Smoking history 18. Surgeries past 10 years 19. Anything of concern that was not listed? 10. Covid Infection? 11. Medical Cannabis card or recreational use of cannabis 12. Gastro intestinal disorders 13. None of the above Health Condition DetailsPlease provide details to items checked above including the condition, the date of treatment and if it is current or date of recoveryHealth Condition Details (Spouse/Partner)Please provide details to items checked above for spouse / partner including the condition, the date of treatment and if it is current or date of recoveryCAPTCHAConsent(Required) I agree to the privacy policy.EmailThis field is for validation purposes and should be left unchanged. We will connect with you for a confidential conversation about your health status.
