Just Exactly
How Healthy
Are You?

It's real scary.  You think you're in perfect health, until that sweet-smiling agent begins asking questions.  Suddenly you freeze up, wondering if you can be covered at all.  Relax, you can ask yourself most of the same questions in advance, and at least be more prepared for them when they are asked. You will find that a wide understanding of various medical info can be of great help throughout your life, whether understanding breast cancer has become important because of a loved one or your own health is threatened because you suddenly need to know the best ways of living with diabetes or some other problem.

Do NOT submit this form unless you do want help finding insurance.  You can answer the questions, then hold the <control> key down and strike the <p> key to print out the form for your own use.  When you leave the page without submitting, all your personal information will vanish.  If you do hit SUBMIT, everything you write in does get submitted.  After your name is removed The NONpersonal information given in this Assessment Form may be used in compiling statistics which help insurance companies to tailor Health Care Coverage to meet future PUBLIC needs.

Assessment Form

(c) copyright 1999 by Browzer Books.

 

Date: 

Full Name of family member: 

First names, Middle Initials and ages of other family members.

Occupations of those with income: 

Ages of family members:  Males Females:  

What prescription drugs are you taking now?
What are these drugs helping you control?
What is the highest amount you spend monthly at drug stores now? 
Describe Your Present Healthcare Coverage
Medical Insurance?  Yes    No   
Existing Riders?    Yes    No   
Other limited medical/surgical plans  Yes    No  
Burial/Final Expense  Yes    No
Cash Cancer Insurance  Yes    No
Cancer Insurance  Yes    No
Home Health Care/Nursing Home  Yes    No
Accident?  Yes    No
Life Insurance?  Yes    No
Existing Medical Conditions
Let us know now so
You can get them covered, not excluded.
Have you ever had --
heart problems? heart attack   heart surgery  Angioplasty?  
Are you still taking medication for your heart?  Yes    No
High Blood Pressure?     Medication for high blood pressure?    hospitalized for high blood pressure? 
High Cholesterol?    What medication are you taking? 
Kidney problems?    Lung problems? 
Diabetes?    Is it controlled with -- Insulin?    Pills?    Diet   
Pregnancy complications?    Are you now pregnant?   Yes    No
*  

No information contained on this site should be used as a substitute for the advice of an appropriately qualified and licensed professional in that particular field. 

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