Long-Term Care Insurance
Pre-qualification Questionnaire
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1. Please list all prescription medications and the specific reasons
they are being taken. If possible, indicate the dosage, frequency of
use, and the dates they were first prescribed. |
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2. When was your last visit to a physician? What was the reason? When
was your last physical exam? What were the results of the exam (normal)? |
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3. Has surgery been recommended and not yet performed? Has surgery been
performed in the past and for what reason? |
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4. Have you been hospitalized within the past 5 years? If the answer is
yes, please list the reason(s) and date(s). Also indicate the date of
the last treatment. |
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5. Do you use a cane, walker, or wheelchair? If so, please indicate the
device used and frequency. |
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6. Have you used tobacco products in the past 5 years? What kind? |
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7. What is your height and weight? Has there been a significant
increase or decrease in weight within the past year? If yes, state the
reason. |
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8. Have you ever been diagnosed with cancer? If yes, please indicate
the stage or grade of the cancer and the date of the last treatment. |
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10. Please list any other medical conditions or concerns: |
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