Free Health Screening for Long Term Care

Many companies are very selective in offering coverage. Most have a precise health profile of the ideal candidate. Complete and submit the following questions regarding your health. Your answers will be analyzed by a properly licensed and contracted insurance agent (meeting all statutory requirements) who will contact you to discuss your insurance options. Please note that your name and email address are required.

Title Suffix	Name
Address	City St	Zip County
Phone number ()	Date of Birth	Marital Status
Email	Height Wt (lbs)	Sex

If yes to any of the above, explain:

1. During the past 5 years have you received medical advice or treatment for any of the following:	Yes	No
a. Emphysema, shortness of breath, chronic cough, or any chronic lung disorder?
b. Any disorders of the heart, circulatory system, blood, artery grafts, paralysis, stroke, TIA or high blood pressure?
c. Bone, joint or spine disease, disorder or surgery?
d. Muscular disorder, diabetes, cancer, Hodgkin's disease, or melanoma?
e. Liver, digestive, colon, rectal, kidney or urinary system disorder?
2. Have you ever been diagnosed or treated for cirrhosis of the liver, Alzheimer's disease, dementia, memory loss, cerebral palsy, multiple sclerosis, chronic brain syndrome, AIDS or AIDS-related complex, congestive heart failure, lupus, Parkinson's disease, alcoholism, substance abuse, any mental or emotional disease or disorder, neurogenic bladder?
If yes to question 2, explain:
3. Do you ever use a wheelchair, walker, cane or hospital bed?
4. Within the past two years have you been confined to a nursing home or received home health care?
5. Do you use any medical appliance such as a catheter, oxygen equipment, respirator or dialysis machine?
6. Within the past 5 years, have you been confined to a hospital?
If yes to question 6, list dates and treatments:
7. During the past 12 months have you sought medical advice or treatment for loss of appetite, falling, fainting, unstable gait, bladder control, dizziness or deterioration of vision?
If yes to question 7, explain:
8. Are you currently being treated for diabetes?
9. Are you currently taking any prescription medication?
If yes, list the type of medication, the reason for taking it and the dosage:
10. Have you used any tobacco products within the last 3 years?
I found out about this site from:

Your answers will be held in compliance with applicable privacy laws and will not be used for any purpose other than our in-house evaluation of your Long Term Care Insurance needs. *Completion of underwriting and approval of a fully completed and signed insurance application is required before any coverage can be offered.