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Home » Medicare Supplement Prescreen

Medicare Supplement Prescreen

Medicare Supplement Prescreen Questionnaire

Name

IMPORTANT – In an effort for us to better help you, please include more detailed information such as A) year of occurence, B) if the condition is resolved or a C) current condition that has been under control for however long.

Please check the boxes that apply to your health history

Circulatory System

Angioplasty
MM slash DD slash YYYY
Any Heart Condition
MM slash DD slash YYYY
Arterial Disease
MM slash DD slash YYYY
Arterial Fibrillation
MM slash DD slash YYYY
Cardiomyopathy
MM slash DD slash YYYY
Congestive Heart Failure
MM slash DD slash YYYY
Enlarged Heart
MM slash DD slash YYYY
Heart Artery Blockage
MM slash DD slash YYYY
Heart Attack
MM slash DD slash YYYY
Heart Rhythm Disorders or Pacemaker
MM slash DD slash YYYY
Heart/Coronary Artery/Carotid Artery Disease/Angina
MM slash DD slash YYYY
Peripheral Vascular Disease
MM slash DD slash YYYY
Stroke
MM slash DD slash YYYY
TIA
MM slash DD slash YYYY
Unopened Aneurysm
MM slash DD slash YYYY

Diabetes

Diabetes Dependent on Insulin
MM slash DD slash YYYY
Diabetes With Medication Stipulations
MM slash DD slash YYYY

Diabetes With Complications

Diabetes With Any Heart Condition Including High Blood Pressure
MM slash DD slash YYYY
Diabetes With Arterial Disease
MM slash DD slash YYYY
Diabetes With Congestive Heart Failure
MM slash DD slash YYYY
Diabetes With Heart Artery Blockage
MM slash DD slash YYYY
Diabetes With Heart Attack
MM slash DD slash YYYY
Diabetes With Kidney Disease
MM slash DD slash YYYY
Diabetes With Kidney Failure
MM slash DD slash YYYY
Diabetes With Neuropathy
MM slash DD slash YYYY
Diabetes With Peripheral Vascular Disease
MM slash DD slash YYYY
Diabetes With Received/Awaiting an Organ Transplant
MM slash DD slash YYYY
Diabetes With Stroke
MM slash DD slash YYYY
Diabetic Retinopathy
MM slash DD slash YYYY

Digestive System

Any Liver Problem
MM slash DD slash YYYY
Cirrhosis
MM slash DD slash YYYY
Crohn's Disease
MM slash DD slash YYYY
Hepatitis
MM slash DD slash YYYY
Ulcerative Colitis
MM slash DD slash YYYY

Disabled

Amputation Caused by Disease
MM slash DD slash YYYY
Bedridden
MM slash DD slash YYYY
Confined to a Nursing Facility
MM slash DD slash YYYY
Confined to a Wheelchair
MM slash DD slash YYYY
Falls
MM slash DD slash YYYY
Hospitalized
MM slash DD slash YYYY
Physical Therapy
MM slash DD slash YYYY
Require Assistance With Activities of Daily Living
MM slash DD slash YYYY
Require the Use of Home Health Care Agency
MM slash DD slash YYYY

Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders

Addison's Disease
MM slash DD slash YYYY
Any Lipidosis Including Gaucher's, Tay-Sachs or Wolmans
MM slash DD slash YYYY
Disorder of Pancreas
MM slash DD slash YYYY

Genitourinary System

Kidney Disease/Failure, Dialysis, Renal Insufficiency/Failure
MM slash DD slash YYYY

Immune Disease

AIDS or AIDS Related Complex
MM slash DD slash YYYY
HIV Positive Diagnosis
MM slash DD slash YYYY

Mental Disorders

Alcoholism or Drug Abuse
MM slash DD slash YYYY
Alcoholism or Drug Abuse
MM slash DD slash YYYY

Musculoskeletal System and Connective Tissue

Advised to Have Joint Replacement
MM slash DD slash YYYY
Connective Tissue Disorder
MM slash DD slash YYYY
Crippling Rheumatoid Arthritis/Degenerative Bone Diseases
MM slash DD slash YYYY
Osteoporosis With Fractures
MM slash DD slash YYYY
Other Bone Injuries
MM slash DD slash YYYY
Other Bone Paget's Disease
MM slash DD slash YYYY
Systemic Lupus
MM slash DD slash YYYY

Neoplasms

Bone Marrow Transplant
MM slash DD slash YYYY
Hodgkin's Disease/Lymphoma
MM slash DD slash YYYY
Internal Cancer
MM slash DD slash YYYY
Leukemia
MM slash DD slash YYYY
Malignant Melanoma
MM slash DD slash YYYY
Multiple Myeloma
MM slash DD slash YYYY
Stem Cell Transplant
MM slash DD slash YYYY

Nervous System

Cerebral Palsy
MM slash DD slash YYYY
Huntington's Disease
MM slash DD slash YYYY
Mental or Nervous Disorder Requiring Psychiatric Care
MM slash DD slash YYYY
Multiple or Lateral Sclerosis/Lou Gehrig's Disease
MM slash DD slash YYYY
Myasthenia Gravis
MM slash DD slash YYYY
Other Cognitive Disorder
MM slash DD slash YYYY
Other Neurological Conditions
MM slash DD slash YYYY
Parkinson Disease
MM slash DD slash YYYY
Senile Dementia/Alzheimer's Disease
MM slash DD slash YYYY

Respiratory System

COPD/Cold/Emphysema
MM slash DD slash YYYY
Lung/Respiratory With Assistance
MM slash DD slash YYYY
Lung/Respiratory and Tobacco
MM slash DD slash YYYY
Other Chronic Pulmonary Disorders
MM slash DD slash YYYY

Surgery, Medical Tests, Etc.

Cataract Surgery
MM slash DD slash YYYY
Heart or Valve Surgery Including Bypass & Stents
MM slash DD slash YYYY
Organ Transplant
MM slash DD slash YYYY
PSA > 4.5, Age < 70, No History of Prostate
MM slash DD slash YYYY
PSA > 6.5, Age > 70, No History of Prostate
MM slash DD slash YYYY
Advised to have Surgery, Medical Tests, Treatment, or Therapy not Performed
MM slash DD slash YYYY

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