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Below are some preliminary health questions if you're considering our Long Term Care coverage.
Have you had, do you currently have or have you been medically diagnosed
as having or being treated for:
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1. Yes No
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Alzheimer's disease, organic brain syndrome, dementia, frequent or persistent forgetfulness, mental retardation or serillity? |
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Yes No
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Parkinson's disease or syndrome, multiple sclerosis, amyotrophic lateral sclerosis (Lou Gehrig disease) or muscular dystrophy? |
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Yes No
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Stroke or any other type of cerebral vascular accident (CVA) or transient ischemic attack (TIA)? |
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a)within the last 5 years b)with residual impairment c)with multiple events, or d) in combination with diabetes, circulatory or heart disease or tobacco use |
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Yes No
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Immune Deficiency Disorder, AIDS (Acquired Immune Deficiency Syndrome), ARC (AIDS related complex) any AIDS conditions(s) or Tested positive for antibodies to the AIDS virus? |
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Yes No
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Cancer with metastasis, or cancer treated in the past 24 months with chemotherapy, radiation, surgery or bone marrow transplant (except basal cell cancer, or early stage breast or prostate cancer)? |
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Yes No
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Cirrhosis of the liver? |
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Yes No
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Emphysema, chronic obstructive pulmonary disease or any chronic respiratory disease in combination with smoking? |
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Yes No
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Congestive heart failure for which you are currently being treated (including treatment by mediation)? |
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Yes No
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Diabetes with amputation or complications affecting the kidney? |
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Yes No
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Schizophrenia or any other mental or nervous disorder for which you have been hospitalized in the past 2 years or have had multiple hospitalizations? |
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2. Yes No
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Have you had or have you been advised by a physician to have any organ transplant? |
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3. Yes No
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Do you currently use a walker, wheelchair or respirator? |
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4. Yes No
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Do you currently receive dialysis or oxygen treatment? |
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5. Yes No
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Are you currently residing in a nursing home or assisted living facility, or are you receiving home health care services or attending adult day care? |
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6. Yes No
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Do you need assistance or supervision in performing any of the following activities: moving in or out of a chair or bed, bathing, dressing, eating, toileting, continence or walking? |