LastName *
First Name*
Email Address:
Street Address *
City *
State *
Zip *
Phone *
Birth Date *
Gender
Height:
Weight::
Are you married?
If yes, Spouse's Birth Date
Height(spouse):
Weight(spouse):
Do you smoke?
Spouse Smoke?
Are you diabetic?
Spouse diabetic?
Are you insulin dependent?
Spouse insulin dependent?
Do you use a cane?
Spouse use a cane?
Do you use a walker?
Spouse use a walker?
Do you use a wheelchair?
Spouse use a wheelchair?
Do you use any other equipment?
Spouse use any other equipment?
Please explain if you have required assistance with everyday activities in the past 2 years?
Please explain if your spouse has required assistance with everyday activities in the past 2 years?
In the past 5 years have you: (Check all that apply)
Please describe your particular health problems:
In the past 5 years has your spouse: (Check all that apply)
Please describe your spouse's particular health problems:
Prescribed Medications:
Spouse's Prescribed Medications:
Do you currently own a long-term care policy?
Does your spouse currently own a long-term care policy?
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