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Long-Term Care Insurance Prequalification

Answer a few questions to help us prequalify you for long-term care (LTC) insurance. This questionnaire is for pre-screening only and does not guarantee coverage. Please answer as accurately as possible.

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Who is your insurance agent or who provided this prequalification form to you? ^*

Please include their name, email address, and phone number.

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Client Identifier/Nickname ^*

For HIPAA security purposes, create a nickname or reference name for you or your client. Please do not use your real name.

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Date of birth ^*

mm/dd/yyyy

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Height (in feet and inches) ^*

Example: 5'8" or 68 inches

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Weight (in pounds) ^*

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Do you currently use tobacco or nicotine products (including cigarettes, cigars, vape/e-cigarettes, chewing tobacco, nicotine pouches, or nicotine replacement)? ^*

Yes

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Tobacco/nicotine use details

Describe type (cigarettes, cigars, vaping, chewing, patches, etc.), frequency, duration, and any quit attempts.

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Do you currently use marijuana/THC (smoking, vaping, edibles, or other)? ^*

Yes

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Marijuana/THC use details

Describe method (smoking, vaping, edibles), frequency, duration, and medical vs recreational use.

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Have you ever been diagnosed with diabetes or pre-diabetes? ^*

Yes

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How is your diabetes managed? (Select the best answer) ^*

Diet/exercise only

Oral medication(s)

Non-insulin injectable medication(s)

Insulin

Combination (multiple types)

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Average daily insulin dosage (units) ^*

Approximate total units per day (e.g., 20-30 units). Include types if multiple (e.g., long-acting + bolus).

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Any diabetes complications? ^*

Examples: neuropathy, retinopathy, kidney disease, foot ulcers, amputations.

Yes

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Diabetes complications details ^*

List complications and approximate dates (if known).

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Have you ever been diagnosed with cancer (excluding non-melanoma skin cancer, if applicable)? ^*

Yes

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Cancer details ^*

Type(s) of cancer, stage/grade (if known), diagnosis date(s), treatment received, and current status (in remission, active, etc.).

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Have you had any cardiac or vascular conditions? ^*

Examples: heart attack, coronary artery disease, stents, bypass surgery, heart failure, arrhythmia/AFib, stroke/TIA, peripheral artery disease.

Yes

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Cardiac/vascular history (select all that apply) ^*

Heart attack (MI)

Coronary artery disease

Angioplasty/stent

Bypass surgery (CABG)

Heart failure / cardiomyopathy

Arrhythmia (including AFib)

Pacemaker/ICD

Valve disease or valve replacement/repair

Stroke

TIA (mini-stroke)

Peripheral artery disease

Aneurysm

High blood pressure (hypertension)

High cholesterol

Other

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Cardiac/vascular details ^*

For each condition selected, include approximate dates, procedures, medications, and current status/limitations.

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Have you had any neurological conditions or cognitive concerns? ^*

Examples: Parkinson’s, MS, Alzheimer’s/dementia, seizure disorder, neuropathy, traumatic brain injury.

Yes

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Neurological/cognitive history (select all that apply) ^*

Alzheimer’s disease / dementia

Mild cognitive impairment (MCI)

Parkinson’s disease

Multiple sclerosis (MS)

Stroke with residual effects

Seizure disorder/epilepsy

Neuropathy (non-diabetic)

ALS

Traumatic brain injury (TBI)

Other

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Neurological/cognitive details ^*

Describe diagnosis, dates, treatments, and any ongoing symptoms or functional impact.

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Do you have any physical deficits or mobility limitations? ^*

Examples: use of cane/walker/wheelchair, history of falls, joint replacement, back/neck issues, chronic pain limiting activities.

Yes

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Mobility/physical limitations (select all that apply) ^*

Use cane

Use walker

Use wheelchair/scooter

Need assistance to transfer (bed/chair)

Frequent falls (2+ in last 12 months)

Joint replacement (hip/knee/other)

Chronic back/neck condition

Arthritis limiting activities

Amputation

Handicap placard

Other

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Mobility/physical limitation details ^*

Include diagnoses, dates, surgeries, fall history, and current ability to perform daily activities.

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Do you currently require help with Activities of Daily Living (ADLs)? ^*

Examples: bathing, dressing, toileting, transferring, continence, eating.

Yes

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Which ADLs do you need help with? ^*

Bathing

Dressing

Toileting

Transferring (bed/chair)

Continence

Eating

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ADL assistance details ^*

Who helps you, how often, and since when?

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Other significant medical conditions (select all that apply) ^*

COPD / emphysema / chronic bronchitis

Asthma (moderate/severe)

Sleep apnea (on CPAP/BiPAP)

Chronic kidney disease

Liver disease (cirrhosis/hepatitis)

Rheumatoid arthritis / autoimmune disease

Depression/anxiety (treated)

Bipolar disorder / schizophrenia

Substance use disorder

HIV/AIDS

Organ transplant

None of the above

Other

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Other condition details ^*

For each selected condition, provide diagnosis date, severity, treatment, and current status.

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In the past 24 months, have you been hospitalized, had surgery, or visited the ER? ^*

Yes

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Hospitalization/surgery/ER visit details ^*

Include dates, reasons, and outcomes.

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Do you currently take any prescription medications? ^*

Yes

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Medication list ^*

List medication name, dose (if known), and reason for taking it.

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Have you been advised to have any tests, procedures, or surgeries that are not yet completed? ^*

Yes

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Pending medical follow-ups ^*

Describe what is pending and why.

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Do you currently have a primary care physician (PCP)? ^*

Yes

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Anything else we should know for LTC prequalification?

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Thank you! 🙌

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