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Long Term Care

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Full Name:
Date of Birth:
Address:
City:
State
Zip Code:
Phone Number
Email Address:
Do you currently have other long term care coverage:
Health Condition:
Smoker:
Current Medications:
Do you currently need assistance for bathing, dressing, eating, moving in/out of bed or chairs, toileting, bowel or bladder control:
Do you use a walker, wheelchair, oxygen,
dialysis, respirator, quad cane or motorized cart:
Within the past 10 years, have you been diagonosed or treated for: alzheimer's, chronic memory loss, senility, dementia, Lou Gehrig's Disease, MS, parkinson's muscular distrophy, cerebral palsy or spina bifida:
Within the past 10 years have you been diagnosed or treated for:
multiple episodes of strokes or transient ischemic attacks, cirrhosis
of the liver, systemic lupus or polycystic kidney disease,
AIDS, HIV or AIDS related complex:
Have you had a heart, back or spine
surgery within the past 6 months:
Have you had a heart attack wthin the past 12 months:
Have you had a transient ischemic attack,
a stroke or mini stroke within the past 12 months
How did you hear about us:
   

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