Long Term CarePersonal Information:Last NameFirst NameEmail Street AddressCityStateZipPhoneBirth Date MM slash DD slash YYYY Gender Male FemaleHeightWeightAre you married? Male FemaleIf yes, Spouse's Birth Date MM slash DD slash YYYY Height(spouse)Weight(spouse)Fill in Spouse if Spouse is also applyingDo you smoke? Yes NoSpouse Smoke? Yes NoAre you diabetic? Yes NoSpouse diabetic? Yes NoAre you insulin dependent? Yes NoSpouse insulin dependent? Yes NoDo you use a cane? Yes NoSpouse use a cane? Yes NoDo you use a walker? Yes NoSpouse use a walker? Yes NoDo you use a wheelchair? Yes NoSpouse use a wheelchair? Yes NoDo you use any other equipment? Yes NoSpouse use any other equipment? Yes NoPlease 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?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) been confined to a hospital? nursing home? had home care? had long-term care? received rehabilitation?Please describe your particular health problemsIn the past 5 years has your spouse: (Check all that apply) been confined to a hospital? nursing home? had home care? had long-term care? received rehabilitation?Please describe your spouse's particular health problemsPrescribed MedicationsSpouse's Prescribed MedicationsDo you currently own a long-term care policy? Yes NoDoes your spouse currently own a long-term care policy? Yes NoCAPTCHACommentsThis field is for validation purposes and should be left unchanged.
