Has any person applying for coverage been advised, counseled, tested, diagnosed, treated, hospitalized or recommended for
treatment within the last 10 years for the following: Please check Yes or No. If any boxes are checked “Yes” ( Yes), also circle
the condition, e.g. migraines , and give details on the next page.
" " "
A. Migraines; headaches; carpal tunnel syndrome; seizure disorder;
paralysis; multiple sclerosis; any neurological disorder, or any
disorder of the central nervous system? ................. Yes No
B. Attention deficit disorder; anxiety, depression or chemical
imbalance; any behavioral, emotional or eating disorder; mental
retardation; bipolar disorder or psychosis; psychotherapy;
marital or any form of counseling or therapy? ...... Yes No
C. Chest pain or palpitations; heart murmur;
mitral valve prolapse; heart attack, stroke or TIA,
any other heart or circulatory disorder or condition,
or hypertension/high blood pressure (HBP)?......... Yes No
If “Yes” to HBP, provide 3 readings and their dates w/in the last year
D. Varicose veins/spider veins/varicosities; elevated
cholesterol or lipids; anemia; blood clot or any
other blood disorder?............................................... Yes No
E. Asthma; allergies; sinusitis; bronchitis; pneumonia;
tuberculosis; apnea; chronic obstructive pulmonary disease
(COPD); emphysema; or any breathing difficulty, lung
or respiratory disease, disorder or condition? ........ Yes No
F. Hernia; colitis; chronic diarrhea or intestinal problems;
hemorrhoids or rectal disorder; gastroesophageal
reflux; any disorder of the esophagus; ulcer of the
stomach or duodenum, or any other digestive
disorder or condition? ............................................. Yes No
G. Any disease or disorder of the gallbladder, pancreas or
liver; elevated liver function tests; cirrhosis; hepatitis?
(indicate type of hepatitis )..... Yes No
H. Cancer; tumor; growth; cyst; polyp; enlarged lymph nodes;
leukemia? (indicate diagnosis and location
) ..... Yes No
QUESTION CONTINUES AT RIGHT
I. Acne; keratosis; psoriasis; basal cell carcinoma; lesions
of the skin or mouth, or any other skin disorder? ......... Yes No
J. Kidney stones; reflux; urinary incontinence or any infection
or disorder of the urinary tract, bladder or kidney? ...... Yes No
K. Breast cyst or nodule; gynecomastia; fibrocystic breast
disease; breast implants, or any other disease or disorder
of the breast?.................................................................... Yes No
L. Arthritis (osteo, rheumatoid, psoriatic); bursitis; herniated,
bulging or slipped disc; gout; temporomandibular joint
syndrome (TMJ); any injury to, disease or disorder of the
spine, back, knees, jaw, bones, muscles, or joints; bunions;
joint replacement; or manipulation therapy? ................ Yes No
M. Thyroid disorder; goiter; Graves disease; diabetes; lupus;
pituitary or adrenal disorder?.......................................... Yes No
N. Cataracts; glaucoma; hearing loss; deviated nasal septum;
or any eye, ear, nose or throat disorder? ........................ Yes No
O. Acquired Immune Deficiency Syndrome (AIDS);
AIDS-Related Complex (ARC); HIV positive or other
immune disorders?.......................................................... Yes No
P. Question for Male Applicants and Dependents Only
Prostate disorder; elevated prostate specific antigen (PSA);
sexually transmitted disease; genital warts; herpes; impotence;
infertility or any other disease or disorder of the genital or
reproductive system? ...................................................... Yes No
Q. Question for Female Applicants and Dependents Only
Fibroid or uterine tumor; ovarian cyst; endometriosis;
cystocele/rectocele; abnormal pap smear; infertility; sexually
transmitted disease; genital warts; herpes; or any other disease
or disorder of the genital or reproductive system? ........ Yes No
). Helpful "structure and guidance" hs included poorly-constructed wage controls in WW-II that excepted fringe benefits, including medical care--which led to the idiotic employment-health care linkage we have today. Un-equitable tax treatment of employer-bought insurance vs individually-bought insurance perpetuated this foolishness. Government-mandated coverages in health insurance policies have also driven up costs and reduced freedom of choice. We've seen where "structure and guidance" leads. Maybe the solution will be found in taking less poison, not in doubling the dose and hoping for an improvement.
