Medicare Questionnaire

MEDICARE SUPPLEMENTAL COVERAGE

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Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Age*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please mark one of the following:

New to MedicareLeaving Group InsuranceCurrently on Medicare
When will your group insurance end?

MonthDayYear
Date
If currently on Medicare - What is your current Medicare Supplement?
What plan types are you interested in (SELECT ALL THAT APPLY):

ABCDFHigh Ded. FGLMNI Dont Know
Tobacco use?

YesNo
1. Are you bedridden or confined to a wheelchair or require the assistance of a motorized mobility aid?

YesNo
Please Explain
2. Are you currently hospitalized or confined to a nursing facility; or have you been hospitalized two or more times within the past year?

YesNo
Please Explain
3. Have you been advised by a physician to have surgery, medical tests, treatment or therapy that has not been performed?

YesNo
Please Explain
4. Is surgery, including cataract, anticipated in the next 12 months?

YesNo
Please Explain
5. During the past 2 years, have you seen a physician, been diagnosed, treated, or taken medication for (a-k):
a. Amyotrophic lateral sclerosis (ALS), multiple sclerosis, Parkinson’s disease, systemic lupus or myasthenia gravis?

YesNo
Please Explain
b. Organ transplant, chronic kidney disease, kidney failure or cirrhosis of the liver, Hepatitis, or systemic Lupus?

YesNo
Please Explain
c. AIDS or HIV positive?

YesNo
d. Alzheimer’s disease or memory loss or dementia?

YesNo
e. Leukemia, internal cancer, lymphoma, melanoma or multiple myeloma?

YesNo
If Yes to question 5(e) has your last treatment been longer than 5 years?

YesNo
f. Heart valve disease, carotid artery disease, peripheral vascular disease, coronary artery disease, angina, cardiomyopathy, congestive heart failure or atrial fibrillation?

YesNo
If Yes to question 5(f) has your last treatment been longer than 5 years?

YesNot
Please Explain
g. Skin ulcer or amputation due to disease?

YesNo
h. Alcohol or drug abuse?

YesNo
j. Complications of diabetes such as neuropathy (numbness, tingling, or burning in arms or legs), Retinopathy (eye damage), any heart disorder (including hypertension/high blood pressure), or kidney damage or diabetes that isn’t under control?

YesNo
k. Disabling Arthritis, Paget’s Disease of the bone or Rheumatoid Arthritis?

YesNo
Please Explain
6. During the past 2 years have you had a heart attack, heart surgery including angioplasty, bypass or stent placement or surgery for carotid artery peripheral vascular disease, a stroke or TIA (Transient Ischemic Attack)?

YesNo
If Yes to question 6, has your last treatment been longer than 5 years?

YesNo
7. In the past 12 months, have you used oxygen to assist with breathing (except when hospitalized)?

YesNo
8. Diabetes that has required more than 50 units of insulin daily or more than two medications (insulin or oral)?

YesNo
Please Explain
9. Are you currently using the services of a home health care agency?

YesNo
10. Do you require or receive any assistance with any of your activities of daily living such as transferring, bathing, toileting, eating, dressing or continence?

YesNo
Please Explain
11. Do you now, or during the past 5 years have you received medical treatment, or been advised to have treatment, surgery or medication for osteoporosis with fracture or Spinal Stenosis?

YesNo
12. Do you have sleep apnea?

YesNo
13. Do you have COPD?

YesNo
14. Do you currently take prescribed medications?

YesNo
Medications
What pharmacy do you like to go to?
List up to 2 pharmacies
Should be Empty:

MEDICARE SUPPLEMENTAL COVERAGE