Just How Healthy ARE You?

See if we can't save you $100 or more.
Click on any type of insurance you want to save money on.
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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.

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

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

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