Long Term Care Personal Information: Last NameFirst NameEmail Street AddressCityStateZipPhoneBirth Date MM slash DD slash YYYY Gender Male Female HeightWeightAre you married? Male Female If 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 No Spouse Smoke? Yes No Are you diabetic? Yes No Spouse diabetic? Yes No Are you insulin dependent? Yes No Spouse insulin dependent? Yes No Do you use a cane? Yes No Spouse use a cane? Yes No Do you use a walker? Yes No Spouse use a walker? Yes No Do you use a wheelchair? Yes No Spouse use a wheelchair? Yes No Do you use any other equipment? Yes No Spouse use any other equipment? Yes No 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?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 No Does your spouse currently own a long-term care policy? Yes No CAPTCHAEmailThis field is for validation purposes and should be left unchanged.