Easy Insurance
Client Intake.

Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:

Select all that apply.

Are you currently:

Select all that apply.

Has a member of the medical profession indicated that your life expectancy is 12 months or less, or recommended you be added to a transplant list?

In the past 5 years, have you attempted suicide?

Have you ever been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:

Select all that apply.

In the past 5 years, have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:

Select all that apply.

In the past 10 years, have you been diagnosed, treated, tested positive for, or been given medical advice by a member of the medical profession for:

Select all that apply.

Have you ever been diagnosed, tested positive for, or been given medical advice by a member of the medical profession for: Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV)?

In the past 12 months, have you been confined to a wheelchair or used supplemental oxygen (except in the case of a temporary condition immediately following injury or medical treatment not to exceed 3 months time)?

In the past 12 months, have you been hospitalized more than 2 times (excluding childbirth)?

In the past 6 months, have you been advised by a member of the medical profession to have any tests, surgery, or hospitalization (except for those related to HIV or AIDS), which have not been completed — or are you waiting for a medical diagnosis or the results of medical tests or procedures?