Health History – ALL
QUESTIONS MUST BE ANSWERED OR THE APPLICATION MAY BE RETURNED AND/OR
REJECTED.
If you answer "Yes" to any question in this section, you must give
complete details on the following screen. If the question does not apply to
anyone listed on the application, please answer "No".
Has any person listed on this application had a clear, distinct symptom that
would cause an ordinarily prudent person to seek advice or treatment, or had
treatment or consultation recommended, received treatment, or been
hospitalized for any of the following conditions listed in questions 1
through 24 within the last 10 years:
1.
Frequent and/or severe headaches, migraines, seizures, epilepsy,
multiple sclerosis, or any other neurological or central nervous system
disorder(s)*
YesNo
2.
Dizziness, weakness, fainting, numbness/tingling, head injury,
paralysis, stroke, confusion, memory loss, loss of consciousness,
narcolepsy, or any similar symptoms*
YesNo
3.
Chest pain, high or low blood pressure, heart disease, heart attack,
heart murmur, palpitations, pacemaker, or any other heart disorder or
condition*
YesNo
4.
Poor circulation, blood clot, varicose veins, enlarged lymph nodes,
blood/bleeding disorder, anemia, rheumatic fever, or any other
circulatory condition*
YesNo
5.
Allergies, difficulty breathing, shortness of breath, asthma, chronic
cough, spitting/coughing up blood, respiratory/lung infections,
sinusitis, bronchitis, pneumonia, reactive airway disease (RAD),
pneumocystis carinii pneumonia (PCP), tuberculosis, emphysema, or any
other respiratory disorder or condition*
YesNo
6.
Diseases or problems of the nose, nosebleeds, polyps, deviated nasal
septum, excessive snoring, or use of a sleep monitoring device*
YesNo
7.
Diseases or problems of the mouth/gums, throat/swallowing, tonsils,
adenoids, jaw/chewing problems or TMJ*
YesNo
8.
Gastric reflux, ulcers, hernia, intestinal problems, diverticulitis,
colitis, diarrhea, rectal problems/bleeding, polyps, hemorrhoids, or any
other digestive disorder or condition*
Kidney/bladder/urinary tract infections, stones, incontinence, blood in
urine or any other disease or disorders of the kidneys or urinary system*
YesNo
11.
Bone, joint and/or muscle pain, injury or disorder of
joint/tendon/ligament/disc, weakness of back/spine/neck/joint, fracture,
sprain/strain, fibromyalgia, arthritis, gout, polio or any other
musculoskeletal disorder*
Is any applicant a candidate for, or a recipient of an organ or bone
marrow transplant?*
YesNo
16.
Skin infections, cancer, melanoma, lesion, psoriasis, keratosis, warts,
ulcers, birthmarks, severe burns, acne, fungal infections, Kaposi's
sarcoma, eczema, dermatitis, hyperhidrosis, herpes, scars/keloids,
cosmetic or reconstructive surgery, or any other skin conditions*
YesNo
17.
Sexually transmitted disease, such as herpes, genital warts, etc*
YesNo
18.
Male Applicants
a)
Prostate, undescended testes, infertility, low sperm count, impotence,
sexual dysfunction, or implant
YesNo
b)
Is any male listed on this application expecting a child or in the
process of adoption or surrogate pregnancy with anyone, whether or not
the mother is listed on this application?
YesNo
19.
Female Applicants
a)
Breast disorder/cyst, lump, fibroid tumors, silicone injections, or
implants
Date and result of last pelvic exam/Pap smear for each female over 16:
d)
Is the applicant, spouse or any female dependent, whether or not listed
on the application, currently pregnant, or in the process of adoption or
surrogate pregnancy?
YesNo
20.
Diseases or problems of the eyes or sight, crossed eyes, glaucoma,
cataracts, detached retina or blurred vision*
YesNo
21.
Diseases or problems of the ears or hearing, implant, or hearing aid*
YesNo
22.
Eating disorder, depression, anxiety, counseling, member of a support
group, bi-polar, chemical imbalance, attention deficit disorder,
schizophrenia, obsessive-compulsive, panic disorder, etc.*
YesNo
23.
Mental or physical impairment or deformity, congenital abnormalities or
birth defects*
YesNo
If yes, specify:
If additional space is required, please provide additional details
when so indicated later in the application process.
24.
Has any applicant consulted a provider for any condition or symptom(s)
for which a diagnosis has not been established?*
YesNo
Has any person listed on the application ever:
25.
Had cancer, tumor/growth, leukemia, or cyst?*
YesNo
26.
Had an abnormal physical exam, laboratory results, x-rays, EKG, MRI, CT
scan or been advised to undergo further testing surgery, or treatment?*
YesNo
27.
Seen, been a patient in a hospital, clinic, or other medical facility,
received treatment from or consulted any doctor, or other person
providing health care services for any other condition or
symptom(s) (excluding childbirth) not listed on this application?
*
YesNo
28.
Been diagnosed as having or received treatment by a physician or health
care professional for AIDS (Acquired Immune Deficiency Syndrome), ARC
(AIDS Related Complex) or tested positive for HIV (Human
Immunodeficiency Virus)?*
YesNo
IMPORTANT: Applicant's medical conditions, which occur after the
signature date and before the approval date that come to UniCare's
attention, may be considered in the final underwriting decision.
Other Health Questions
1.
Has any applicant ever smoked or used any tobacco products - such as:
cigarettes, pipe, cigar, snuff or chewing tobacco?*
YesNo
2.
Has any applicant used illegal or controlled drugs, or substances such
as marijuana, cocaine, methamphetamines in the last 10 years, or been
diagnosed as chemically or alcohol dependent?*
YesNo
3.
Has any applicant ever used any illegal or controlled I.V. drugs?*
YesNo
4.
Has any applicant consumed any alcoholic beverages in the last 6 months?*
Amount: A drink is 12 oz. of beer, 6 oz. of wine, or 1 oz. of liquor.
YesNo
5.
Has any applicant been advised to reduce alcohol intake within the past
10 years?*
YesNo
If
yes, indicate which applicants and the date discontinued: