Long Term Care

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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