LTC Medical Profile Questionnaire

MCC Brokerage Corporation
Phone: 813-935-8361   Toll: 800-783-5642   Fax: 813-933-6919
 

Agent: Phone:     Fax:     Email:

  Date of Birth: Height Weight Have you used tobacco products in the last 12 months?
Client 1:

 

 

 

                                                               
Client 2:

 

 

                                                            

            1.    Do you have symptoms of or have you received medical advice, diagnosis or treatment, or consulted with a member
                   of the medical profession for any of the following conditions within the last fives years?

  Client 1 Client 2   Client 1 Client 2   Client 1 Client 2
Heart Disease     Bowel Disorders     Reproductive Disorders    
Coronary Artery Disease     Bladder Disorders     Respiratory Disorders    
Circulatory Disorders     Prostate Disorder     Parkinson's Disease    
High Blood Pressure     Kidney Disorder     Seizure    
Leukemia     Depression     Tremor    
Lymphoma     Alcoholism     Diabetes    
Cancer     Liver Disorder     Alzheimer's Disease    
Paralysis     Osteoporosis     Dementia    
Stroke, TIA     Arthritis     Memory Loss    

 

  Client 1 Client 2
  1. Within the last 5 years, have you been hospitalized or consulted or been treated by a member of the medical profession for any reason not Previously stated?
    
  1. Do you currently use any assistive or mechanical devices?
    
  1. Have you ever received home health care or been confined to a nursing home or rehabilitation facility? 
   
  1. Do you currently need or receive any help in doing any of your activities of daily living?
    
     

Details:

Question #       Date of Onset         Details
Question #       Date of Onset         Details
Question #       Date of Onset         Details
Question #       Date of Onset         Details
 

Medications:
Medications:
 

Benefits Client 1 Client 2
Daily Benefit
Elimination
Inflation Option
Benefit Period