Office Phone:

(717) 575-5227

Generic Medicare Supplement Prescreening Questions

Applicant Name:

Are you dependent on a wheelchair or any motorized mobility device? Yes
No
Do any of the following apply to you?
Currently hospitalized, confined to a bed, in a nursing facility or assisted living facility, receiving home health care or physical therapy Yes
No
 
At any time, have you been medically diagnosed, treated, or had surgery for any of the following?
Congestive heart failure, unoperated aneurysm, defibrillator Yes
No
Leukemia, lymphoma, multiple myeloma, cirrhosis Yes
No
Parkinson's Disease, Lou Gehrig's Disease, Alzheimer's Disease, dementia, multiple sclerosis, muscular dystrophy, cerebral palsy Yes
No
Chronic kidney disease, kidney failure, kidney disease requiring dialysis, renal insufficiency, Addison's Disease Yes
No
Any condition requiring a bone marrow transplant or stem cell transplant, any condition requiring an organ transplant Yes
No
Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), tested positive for the Human Immunodeficiency Virus (HIV) Yes
No
 
Do you have diabetes?
That requires use of insulin Yes
No
With complications including retinopathy, neuropathy, peripheral vascular or arterial disease or heart artery blockage Yes
No
With history of heart attack or stroke (at any time) Yes
No
Treated with medication that has been changed or adjusted in the past 12 months because of uncontrolled blood sugar Yes
No
 
Within the past 36 months, have you been medically diagnosed, treated, or had surgery for any of the following?
Alcoholism, drug abuse Yes
No
Cardiomyopathy, atrial fibrillation, anemia requiring repeated blood transfusions, any other blood disorder Yes
No
Internal cancer, melanoma, Hodgkin's Disease Yes
No
Hepatitis, disorder of the pancreas Yes
No
 
Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?
Enlarged heart, transient ischemic attack (TIA), stroke, peripheral vascular or arterial disease, neuropathy, amputation caused by disease Yes
No
Myasthenia gravis, systemic lupus or connective tissue disorder Yes
No
Osteoporosis with fractures, Paget's Disease, arthritis that restricts mobility or the activities of daily living Yes
No
Any lung or respiratory disorder requiring the use of a nebulizer or oxygen, or 3 or more medications for lung or respiratory disorder Yes
No
Any lung or respiratory disorder and currently use tobacco products Yes
No
 
Within the past 12 months, have you been advised by a medical professional to have treatment, further evaluation, diagnostic testing, any surgery that has not been performed or any pending test results? Yes
No

 
Within the past 12 months, have you been medically diagnosed or, treated, or had surgery for a heart attack, artery blockage, or heart valve disorder? Yes
No
 
Within the past 12 months, have you been medically diagnosed with wet macular degeneration and have taken or are currently receiving injections? Yes
No
 
Have you used any form of tobacco in the past 12 months? Yes
No
 
Within the past 12 months, do any of the following apply to you?
Had a pacemaker implanted Yes
No
Had a PSA blood test greater than 4.5, under age 70, with no history of prostate cancer Yes
No
Had a PSA blood test greater than 6.5, age 70 or older, with no history of prostate cancer Yes
No
Had a seizure Yes
No
 
Was your last blood pressure reading higher than 175 Systolic or higher than 100 Diastolic? Yes
No
 
Height (feet and inches)
Weight (Pounds)
 
Health History
Within the past 24 months if you have been medically diagnosed, treated, or had surgery for any brain, mental or nervous disorder, provide reason and diagnosis: Yes
No
 
Within the past five years if you have been hospitalized, treated at an outpatient facility, or emergency room, provide reason and diagnosis: Yes
No
 
Prescribed Medication Reason for medication (diagnosis)
 
Physician Information
Your Primary physician:
Phone:
Physician's Office Name:
Physician's Office City:
Physician's Office State

Specialist seen in the past 24 months:
Specialty:
Reason for seeing (diagnosis):

Specialist seen in the past 24 months:
Specialty:
Reason for seeing (diagnosis):

Specialist seen in the past 24 months:
Specialty:
Reason for seeing (diagnosis):


Have you seen any additional physicians other than those listed above in the past 24 months? Yes
No