From: Subject: Date: Mon, 10 Dec 2007 15:03:24 -0500 MIME-Version: 1.0 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: mhtml:file://C:\Documents%20and%20Settings\David\Local%20Settings\Temporary%20Internet%20Files\Content.MSO\WordWebPagePreview\2FCF8740.mht X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3198

David=20 Schmader Agency

5859 Briar Hill=20 Drive

Solon, Ohio 44139-2366

Phone:=20 440.248-5258

Fax:=20 440.248-5258

E-mail:=20 Schmader@brownschmader.com

 

 

 

Life=20 & LTC Medical Profile=20 Questionnaire
........................................................= .

 

 

 

Agent:=20 Phone:   
Fax:    =20          &nbs= p;            = ;  =20 Email: 

 

Date of=20 Birth:

Height

Weight

Have you used=20 tobacco products in the last 12 months?

Client=20 1:=20  

 




 


 =20

Client=20 2: =




 


 =20

1. Do you = have=20 symptoms of or have you received medical advice, diagnosis or treatment, = or=20 consulted with a member of the medical profession for any of the = following=20 conditions within the last fives years?

 

Client=20 1

Client=20 2

 

Client=20 1

Client=20 2

 

Client=20 1

Client=20 2

Heart=20 Disease

 =20

 =20

Bowel=20 Disorders

 =20

Reproductive=20 Disorders

 =20

 =20

Coronary=20 Artery Disease

 =20

 =20

Bladder=20 Disorders

--

 =20

Respiratory=20 Disorders

 =20

 =20

Circulatory=20 Disorders

 =20

 =20

Prostate=20 Disorder

--

 =20

Parkinson's=20 Disease

 =20

 =20

High Blood=20 Pressure

 =20

 =20

Kidney=20 Disorder

--

 =20

Seizure

 =20

 =20

Leukemia

 =20

 =20

Depression

--

 =20

Tremor

 =20

 =20

Lymphoma

 =20

 =20

Alcoholism

--

 =20

Diabetes

 =20

 =20

Cancer

 =20

 =20

Liver=20 Disorder

--

 =20

Alzheimer's=20 Disease

 =20

 =20

Paralysis

 =20

 =20

Osteoporosis

--

 =20

Dementia

 =20

 =20

Stroke,=20 TIA

 =20

 =20

Arthritis

--

 =20

Memory=20 Loss

 =20

 =20

 

 

 

Client=20 1

Client=20 2

2.

Within the=20 last 5 years, have you been hospitalized or consulted or been = treated by a=20 member of the medical profession for any reason not Previously = stated?=20

 =20

 =20

3.

Do = you=20 currently use any assistive or mechanical devices?

 =20

 =20

4.

Have you ever=20 received home health care or been confined to a nursing home or=20 rehabilitation facility? 

 =20

 =20

5.

Do = you=20 currently need or receive any help in doing any of your activities = of=20 daily living?

 =20

 =20

 

 

 

 

Details:

Question=20 #

 

Date of=20 Onset

 

Details

Question=20 #

 

Date of=20 Onset

 

Details

Question=20 #

 

Date of=20 Onset

 

Details

Question=20 #

 

Date of=20 Onset

 

Details

 

 

Medications:

Medications:

 

LTC = Benefit=20 Description

Client=20 1

Client=20 2

Daily=20 Benefit

Elimination

Inflation=20 Option

Benefit=20 Period

 

Life=20 and
Long Term Care Combo

Client=20 1

Client=20 2

Death=20 Benefit Amt (Quoted as Guaranteed Death Benefit with No Lapse=20 Premium)

Long Term=20 Care Rider Amt (This rider can be issued for up to 100% of the = Death=20 Benefit)

 

Bottom=20 of Form