Health Evaluation Form

Section 1: Employer/Employee Information

Employer Name:
Names of Family Members Applying for Coverage Relationship Date of Birth Gender - Male/Female Height (feet-inches) Weight (pounds)

Section2: Family Health History

Within the past five (5) years has a physician or other licensed healthcare practitioner (“practitioner”) diagnosed or treated you or anyone in your family applying for coverage, or is anyone currently getting treatment? Use an “X” to mark “YES” or “NO” in the boxes heading each category of conditions below and mark with an “X” any of the following conditions that apply.

For all “YES” answers and conditions that you mark with an “X”, provide details in the table on the next page.

A: Heart/Circulatory
 Anemia Angina Angioplasty/Stent Aneurysm Blood Clots Blood Disorder Bypass Cardiac Arrhythmia Chest Pain Congestive Heart Failure Coronary Heart Disease Heart Murmur Hemophilia High/Low Blood Pressure High Cholesterol Pacemaker Palpitations Sickle Cell Anemia Stroke/TIA Varicose Veins Ventricular Tachycardia Other
B: Eyes/Ears/Nose/Throat
 Acoustic Neuroma Cataracts Chronic Sinusitis Cleft Lip/Palate Detached Retina Deviated Septum Ear Infections Glaucoma Retinopathy Other
C: Immune
 ALS AIDS HIV+ Immuno Deficiency Lupus Psoriasis Scleroderma Other
D: Cancer
 Brain Breast Colon Cyst Hodgkin's Disease Leukemia Liver Lung Lymphoma Melanoma Ovarian Pituitary Prostate Stomach Testicular Thyroid Other
Stage of Cancer if known
E: Neurological
 Alzheimer's Disease Cerebral Palsy Epilepsy Head Injury Migraines Multiple Sclerosis Neuritis Paralysis/Hemiplegia Parkinson's Disease Seizures/Convulsions Other
F: Transplants
 Pending On Waiting List Completed Transplant Bone Marrow Stem Cell Organ
G: Arthritis
 Arthritis Osteoarthritis Rheumatoid Arthritis Other
H: Bones/Muscles/Joints
 Bulging/Herniated Disk Carpal Tunnel Syndrome Fibromyalgia/CFS Fractures (Open or Closed) Gout Joint Replacement Knee Muscular Dystrophy Neck/Back Shoulder Spina Bifida Sprain/Strain Other
I: Psychological
 ADD/ADHD Alcoholism Anxiety Autism Bipolar Depression Drug Abuse Eating Disorder Schizophrenia Suicide Attempt Other
J: Diabetes/Endocrine
 Diabetes Controlled By: Diet Oral Medication Insulin Other Adrenal Glands Growth Hormones Hyperthyroidism/Hypothyroidism Other
K: Reproductive
 Breast Disorder Endometriosis Fibroids Menstrual Disorder Ovarian Cysts Other
L: Lung/Respiratory
 Allergies Asthma COPD On Oxygen for COPD Cystic Fibrosis Emphysema Lung Disorder Pneumonia Sarcoidosis Sleep Apnea Tuberculosis Valley Fever Other
M: Intestinal
 Acid Reflux/GERD Colitis/IBD Colon Disorder Crohn's Disease Diverticulitis/Diverticulum Gallbladder Gastric Bypass Hiatal Hernia/Reflux Pancreatitis Ulcer Ulcerative Colitis Other
N: Liver/Kidney/Urniary
 Bladder Disorder Cirrhosis Gaucher's Disease Hepatitis Jaundice Kidney Disorder Kidney Stones Liver Disorder Polycystic Kidney Prostate Renal Failure Other
Please answer the following questions for yourself and for anyone in your family applying for coverage:
 Yes No 1. Is anyone currently pregnant or an expectant parent?
Due Date:
 Yes No a. Has the pregnancy been confirmed by a physician or practitioner?
 Yes No b. Pregnancy complications?
 Yes No c. Multiple births expected?
 Yes No 2. Is anyone currently, or in the past five years has anyone been, a patient in a hospital, clinic, surgi-center, urgent care facility, or other medical facility as an inpatient or outpatient?
 Yes No 3. Does anyone currently use tobacco products, including cigarettes, pipes, cigars or chewing tobacco?
 Yes No 4. Does anyone currently have, or in the past 12 months has anyone had, any of the following?
 Abnormal test or physical results Pending test results Health condition, illness or injury that may require treatment or surgery Tests, treatment or surgery advised Unexplained weight gain/loss or fatigue Worker's Compensation injury or illness condition not mentioned above in Section 2

Please use this table to explain any “YES” answers or items that you marked in Section 2. You may attach additional sheets.

Question Title Name Diagnosis/Treatment Diagnosis Date Treatment Status

Section 3: Family Medication

Are you or anyone in your family applying for coverage currently taking any medications (including “over the counter” or “OTC” medicine) prescribed or recommended by a physician or practitioner?  Yes No

Name Medicine Dosage & Frequency of Use Date Prescribed Date Last Taken or Ongoing Condition(s) Being Taken For

PLEASE NOTE: If you leave out or misrepresent any information, the premium for your coverage may change retroactive to the
date the policy became effective or your policy coverage may become void or voidable . You or your authorized agent is entitled to receive a copy of this form.

Leave a Reply

Your email address will not be published. Required fields are marked *

For all insurance and individual & employee services!