Individual Health Questionnaire

Complete the information below. Fields mirror the paper questionnaire sections.

Group / Application

Group Name

Home Zip Code

Job Title

Employee

First name

Last name

Date of birth

Sex

Enroll in plan?

Yes

If not enrolling, other coverage?

Height — ft

Height — in

Weight now (lbs)

Spouse (if applicable)

First name

Last name

Date of birth

Sex

Enroll spouse?

Yes

If not enrolling, other coverage?

Height — ft

Height — in

Weight now (lbs)

Dependent children

First name

Last name

Date of birth

Sex

Enroll?

Yes

If not enrolling, other coverage?

Height — ft

Height — in

Weight now (lbs)

Health questions (yes/no)

Any major disease/illness affecting you or dependents?

Yes

Anticipated medical/surgical treatment in the next year?

Yes

Currently taking prescription medication?

Yes

Used any tobacco products in the past 5 years?

Yes

Conditions (diagnoses/prognoses)

Please list any of the following: AIDS/HIV, Substance Abuse, Blood Disorders, Cancer (include type), Congenital Disorders, COPD, Cystic Fibrosis, Diabetes, Digestive System (including Crohn's and Colitis), Heart Disease, Kidney Disease, Liver Disease (Hepatitis), Lung Conditions, Pregnancy (including any anticipated complications), Transplants (include type), Multiple Sclerosis, Rheumatoid Arthritis or other major illnesses.

Individual name	First Date	Last Date	Diagnosis	Prognosis	Est. expense

Medications

Individual name	First Date	Last Date	Medication (name & dosage)	Reason	Est. expense

Signature

Employee signature (type full name)

Date

Email (optional - receive submission confirmation)