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EIG Senior CareEveryone is golden

A quick health check

Medicare Supplement health questions

Outside a guaranteed-issue period, a Medicare Supplement plan usually asks about your health before approving you. Answer these questions for the applicant and we'll tell you where you stand.

Nothing is submitted unless you fill in your contact details at the bottom and press Submit. Please don't send medical records here.

If any health question below is answered "Yes," the applicant does not qualify for this insurance and the application cannot be submitted.

0 of 29 answered

1. Are you dependent on a wheelchair or any motorized mobility device?

Applicant A

2. Do any of the following apply to you?

2.ACurrently hospitalized, confined to a bed, in a nursing facility or assisted living facility, receiving home health care or physical therapy

3. At any time, have you been medically diagnosed, treated, or had surgery for any of the following?

3.ACongestive heart failure, unoperated aneurysm, defibrillator

3.BLeukemia, lymphoma, multiple myeloma, cirrhosis

3.CParkinson's Disease, Lou Gehrig's Disease, Alzheimer's Disease, dementia, multiple sclerosis, muscular dystrophy, cerebral palsy

3.DChronic kidney disease, kidney failure, kidney disease requiring dialysis, renal insufficiency, Addison's Disease

3.EAny condition requiring a bone marrow transplant or stem cell transplant, any condition requiring an organ transplant

3.FAcquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), tested positive for the Human Immunodeficiency Virus (HIV)

4. Have you been medically diagnosed or treated by a member of the medical profession for diabetes?

4.AThat requires use of insulin

4.BWith complications including retinopathy, neuropathy, peripheral vascular or arterial disease or heart artery blockage

4.CWith history of heart attack or stroke (at any time)

4.DTreated with medication that has been changed or adjusted in the past 12 months because of uncontrolled blood sugar

5. Within the past 36 months, have you been medically diagnosed, treated, or had surgery for any of the following?

5.AAlcoholism, drug abuse

5.BCardiomyopathy, atrial fibrillation, anemia requiring repeated blood transfusions, any other blood disorder

5.CInternal cancer, melanoma, Hodgkin's Disease

5.DHepatitis, disorder of the pancreas

6. Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?

6.AEnlarged heart, transient ischemic attack (TIA), stroke, peripheral vascular or arterial disease, neuropathy, amputation caused by disease

6.BMyasthenia gravis, systemic lupus or connective tissue disorder

6.COsteoporosis with fractures, Paget's Disease, arthritis that restricts mobility or the activities of daily living

6.DAny lung or respiratory disorder requiring the use of a nebulizer or oxygen, or 3 or more medications for lung or respiratory disorder

6.EAny lung or respiratory disorder and currently use tobacco products

7. Within the past 12 months, have you been advised by a medical professional to have treatment, further evaluation, diagnostic testing, or surgery that has not been performed or do you have pending test results?

Applicant A

8. Within the past 12 months, have you been medically diagnosed or treated, or had surgery for a heart attack, artery blockage, or heart valve disorder?

Applicant A

9. Within the past 12 months, have you been medically diagnosed with wet macular degeneration and have taken or are currently receiving injections?

Applicant A

10. Within the past 12 months, do any of the following apply to you?

10.AHad a pacemaker implanted

10.BHad a PSA blood test greater than 4.5, under age 70, with no history of prostate cancer

10.CHad a PSA blood test greater than 6.5, age 70 or older, with no history of prostate cancer

10.DHad a seizure

11. Was your last blood pressure reading higher than 175 Systolic or higher than 100 Diastolic?

Applicant A

This questionnaire is a pre-screening tool only and is not an application for insurance. Eligibility and final approval are determined by the insurance company's underwriting. EIG Senior Care is a licensed insurance agency. We do not offer every plan available in your area; please contact Medicare.gov or 1-800-MEDICARE for information on all of your options.