Medicare Health Screener

  • Medicare Health Screener

     

    This quick form helps us learn about your health so we can match you with the right Medicare Supplement plan.

    Your answers stay private and are only used by our team to guide our recommendations.

  • Medical Questions – Part A


    Please answer Yes or No to each question, based on your best knowledge and understanding.

  • 1. Are you currently using a wheelchair or any motorized mobility device?*
  • 2. Are you currently in the hospital, confined to a bed, or living in a nursing home or assisted living facility?*

  • The next questions ask whether you’ve ever been diagnosed, treated, or had surgery for any of the following conditions:

  • 3A. Kidney disease (Stages 3–5), kidney failure, or kidney disease requiring dialysis?*
  • 3B. Emphysema, COPD, or other long-term lung or heart-lung conditions requiring oxygen?*
  • 3C. Alzheimer’s disease, dementia, or any other memory or cognitive disorder?*
  • 3D. Parkinson’s, multiple sclerosis (MS), ALS (Lou Gehrig’s Disease), Huntington’s disease, or cerebral palsy?*
  • 3E. Systemic lupus, scleroderma, or myasthenia gravis?*
  • 3F. Chronic hepatitis or cirrhosis?*
  • 3G. AIDS, AIDS-Related Complex (ARC), or have you tested positive for HIV?*
  • 4. Have you had (or been told you need) an organ or stem cell transplant? (Not including corneal implants)?*
  • 5. Have you been diagnosed with osteoporosis?*
  • 5A. If yes, have you had any fractures caused by osteoporosis?*
  • 6. Do you have diabetes?*
  • 6A. If you have diabetes, has it led to any complications such as eye problems (like retinopathy), nerve damage (neuropathy), circulation issues (like peripheral artery or venous disease), stroke, mini-stroke (TIA), any heart condition, or kidney disease?*
  • 6B. Do you have both diabetes and high blood pressure, and have your medications for either condition changed in the past two years?*
  • 6C. Do you take more than two medications—either pills or insulin—for diabetes or high blood pressure??*
  • 6D. Do you take 50 units or more of insulin each day?*
  • 7. Do you have a pacemaker, defibrillator, atrial fibrillation, or another heart rhythm condition?*

  • Medical Questions – Part B


    Please answer Yes or No to each of the following questions. These questions refer to the past two years. Have you been treated for—or has a doctor recommended treatment for—any of the following conditions?

  • 8A. Heart conditions like coronary artery disease, angina (chest pain), heart attack, angioplasty, bypass surgery, or stent placement?*
  • 8B. Serious heart or circulation issues such as cardiomyopathy, congestive heart failure, aneurysm, peripheral artery or vein disease, angioplasty, carotid artery disease, or any heart valve problems?*
  • 8C. Alcohol or drug dependency (including treatment or rehab)?*
  • 8D. Mental health conditions that required treatment in a hospital?*
  • 8E. Internal cancer, lymphoma, or melanoma (not including minor skin cancers like basal cell)?*
  • 8F. Stroke or mini-stroke (also called TIA – transient ischemic attack)?*
  • 8G. Severe joint or bone issues like spinal stenosis, rheumatoid or psoriatic arthritis, or arthritis that limits mobility—or have you been told you may need a joint replacement?*
  • 9. Have you been hospitalized three or more times in the past two years for the same or a similar condition?*
  • 10. Has a doctor diagnosed you with a condition that still requires future care—such as testing, rehab, surgery, or other ongoing treatment.*

  •  If you answered “Yes” to any question above, please provide more details:
     

    1. What is the condition? (Name or type)

    2. When did it begin? (Month and year)

    3. What’s the current status? (Ongoing, remission, resolved, maintenance checkups)

    4.  List the medications you take for this condition.

     Example:

     “Diagnosed with prostate cancer in July 2020. Radiation and surgery completed in September 2020. Now in remission with annual checkups. No medications.”

     

    Your answers help us give you the best, most accurate Medicare Supplement recommendations based on your personal health needs.

    Depending on your responses, some, all, or none of the available carriers may be options. We’ll be in touch soon with next steps. Thank you!

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