Step 2: Qualify for Coverage

Medical History

Any form of tobacco or tobacco cessation product in past 12 months?

Yes

No

1. Please list all drugs prescribed or taken in the past 12 months.

2. Has any applicant been diagnosed with, treated or taken medications for, consulted with, had symptoms of, or been advised to seek treatment for any disease or disorder of the:

a) Lungs or Respiratory system including but not limited to Asthma, Allergies, Pneumonia, Chronic Bronchitis, Emphysema or Sleep Apnea?

Yes

No

b) Heart or Circulatory system including but not limited to High Blood Pressure, Coronary Artery Disease, Heart Attack, Stroke, Heart Murmur, Congestive Heart Failure, Mitral Valve Prolapse, or Irregular Heartbeat?

Yes

No

c) Blood or Blood forming organs including but not limited to Anemia, Hemophilia, or Blood Clots?

Yes

No

d) Stomach, Esophagus, Intestines, Rectum, or Digestive system including by not limited to Ulcers, Colitis, Gastritis, Crohn’s disease, Hernia, Hemorrhoids, or Gallbladder disease?

Yes

No

e) Liver including but not limited to Hepatitis, or Cirrhosis?

Yes

No

f) Kidneys or Urinary System including but not limited to Kidney Stones, Urinary Tract Infections, Cystitis, or Urinary Incontinence?

Yes

No

g) Pancreas including but not limited to Pancreatitis, Diabetes, or Sugar/Glucose Intolerance?

Yes

No

h) Thyroid, Pituitary, Adrenal or Endocrine glands including but not limited to Hyperthyroidism, Graves’ Disease, or Goiter?

Yes

No

i) Neuromuscular system including but not limited to Parkinson’s Disease, Muscular Dystrophy, or Lou Gehrig’s Disease ALS?

Yes

No

j) Muscles, Joints, or Connective Tissues including but not limited to Rheumatism, Arthritis, Rheumatoid Arthritis, Gout, Fibromyalgia, Temporomandibular Joint disorder, (TMJ), Carpal Tunnel Syndrome, Lupus or Lyme disease?

Yes

No

k) Back, Neck or Spine including but not limited to Sprain or Strain, Herniated or Slipped Disc,
Chiropractic Adjustments or Spinal Manipulations?

Yes

No

l) Brain or Central Nervous System including but not limited to Convulsions, Epilepsy, Seizures, Recurrent Headaches, Migraine(s), Dementia, Multiple Sclerosis, or Paralysis?

Yes

No

m) Skin including but not limited to Psoriasis or Eczema?

Yes

No

n) Eyes, Ears, Nose or Throat including but not limited to Glaucoma, Cataracts, Blindness, Tubes in Ears, Deafness or Hearing loss, Cochlear Implants, or Chronic Tonsillitis?

Yes

No

o) Male Applicant(s) – Breast, Prostate, or Male Reproductive System including but not limited to an abnormal PSA test or impotence?

Yes

No

p) Female Applicant(s) - Breast or Female Reproductive System including but not limited to Endometriosis, Pelvic Pain, Menstruation Disorder, Abnormal Pap Test, Cyst or Fibroid Tumors?

Yes

No

q) Female Applicant(s) Has any applicant ever had a Cesarean Section, miscarriage, abortion, or premature delivery? 

Yes

No

3. Is any applicant listed currently pregnant, or expecting a child with anyone, whether or not listed on this application, or in the process of adoption?

Yes

No

4. Has any Applicant ever:

a. received consultation, testing, or counseling for infertility, impotence, in-vitro fertilization, artificial insemination, or surrogacy?

Yes

No

b. been treated for Sexually Transmitted Disease, hormone imbalance or oral contraceptive reaction of any kind?

Yes

No

c. tested positive for the presence of the HIV infection, or been diagnosed as having Acquired Immune Deficiency Syndrome (AIDS), or AIDS Related Complex (ARC)? 

Yes

No

d. had or is any applicant considering any cosmetic or reconstructive surgery, or has any applicant ever had or been diagnosed or treated for a congenital birth defect or bodily deformity, or had or considering an organ transplant? 

Yes

No

e. had or does any applicant have a monitoring device, implants, amputation(s), prosthetic, or internal fixations (i.e. pins, plates, screws, shunt, pacemaker), or been advised to use a walking aid, wheelchair, or any other device or equipment? 

Yes

No

f. had Leukemia, Hodgkin’s Disease, Lymphoma or any other form of Cancer? 

Yes

No

g. had a tumor, cyst or any form of growth? 

Yes

No

h. had mental, emotional or nervous disease or disorder including but not limited to Depression, Anxiety, Bulimia, Anorexia, Bipolar Disorder, Mental Retardation, Learning/Behavior Disorder, or Attention Deficit Disorder? 

Yes

No

i. been advised or treated for alcohol or drug abuse, used illegal drugs, been a member of any alcohol or drug support group, or been given counseling or directive to seek treatment for use or abuse of alcohol or drugs? 

Yes

No

5. In the past five years, has any applicant gone to any health care professional for diagnosis, advice, treatment, checkup or consultation, been recommended treatment, or been confined to a hospital, clinic, or other medical  facility for any condition, disease or disorder not listed above? 

Yes

No

6. Has any applicant been cited for a DW or D or had their driver’s license suspended or revoked in the past 5 years, or currently on probation or been convicted of a felony in the past 10 years? 

Yes

No

7. Are all applicants U.S. Citizen(s) or do all applicants have Permanent Residence status (Green Card)? 

Yes

No

8. Do any applicants participate in any hazardous avocation or sport including but not limited to vehicle racing, skydiving, pilot or student pilot, scuba diving, rock or mountain climbing, or rodeo? 

Yes

No

9. Has any applicant traveled outside the U.S. for more than 30 days in past two years, or does any applicant plan to travel outside the U.S. for more than 30 days in the next two years? 

Yes

No

10. Has any applicant been diagnosed with COVID-19 in the past 45 days?

Yes

No

Please provide details to any "Yes" answers to questions 1 through 10 above in the section below.

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