Disability Form Test – Welcome

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Name
First Middle Last
Primary Phone
Cell Phone*
Work Phone*
Email
Gender*
- Male
- Female
- Other
Date of Birth*
Date Format: MM slash DD slash YYYY
State of Residence
ARE YOU A U.S. CITIZEN or PERMANENT RESIDENT/GREEN CARD HOLDER?
- Yes
- No
Non US Citizen (Hidden)
List Country of Citizenship
Visa
Section Break (Hidden)
HAVE YOU USED TOBACCO or TOBACCO PRODUCTS IN THE LAST 5 YEARS?
- Yes
- No
Tobacco Yes (Hidden)
Which do you use?
- CIGARETTES
- E-CIGARETTES
- CIGARS
- PIPE
- CHEWING TOBACCO
- NICOTINE PATCHES OR GUM
Smoking Frequency (Hidden)
Date you last smoked?
Date Format: MM slash DD slash YYYY
On average, how many per day did you smoke?
Smoking Frequency (Hidden)
Date you last smoked?
Date Format: MM slash DD slash YYYY
On average, how many per day did you smoke?
Cigar Smoking Frequency (Hidden)
Date you last smoked?
Date Format: MM slash DD slash YYYY
On average, how many per day did you smoke?
Pipe Smoking Frequency (Hidden)
Date you last smoked?
Date Format: MM slash DD slash YYYY
On average, how many per day did you smoke?
Chewing Tobacco Frequency (Hidden)
Date you last chewed?
Date Format: MM slash DD slash YYYY
On average, how many per day did you smoke?
Nicotine (Hidden)
Date you last used a nicotine replacement?
Date Format: MM slash DD slash YYYY
Section Break (HIDDEN)
Height
Weight
ARE YOU A PHYSICIAN?
- Yes
- No
Physician Yes (Hidden)
Please List Your Current Specialty
Are you in training?
- Yes
- No
Training Yes (hidden)
Please list the name of your employer/practice/hospital/GME
What is your PGY?
Section Break (hidden)
INDIVIDUAL ANNUAL INCOME OR SALARY (DO NOT INCLUDE SPOUSE OR PARTNER)
DO YOU OWN ANY PART OF OR ARE YOU AN INDEPENDENT CONTRACTOR FOR THE BUSINESS WHERE YOU WORK?*
- Yes
- No

PLEASE LIST ANY INDIVIDUAL DISABILITY INSURANCE COVERAGE YOU OWN
Company
Monthly Benefit
WHEN DID YOU LAST SEE A DOCTOR
Date Format: MM slash DD slash YYYY
FOR WHAT REASON/CONDITION DID YOU LAST SEE THE ABOVE DOCTOR? PLEASE NOTE THE FINDINGS/RESULTS OF YOUR VISIT.
PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING
Medication 1
- Medication 1
Medication 1 Info
Medication Name
Condition / Reason
Date of Diagnosis
Date Format: MM slash DD slash YYYY
Dossage
Frequency
Final Section (Hidden)
PLEASE LIST ANY DIAGNOSED/KNOWN HEALTH ISSUES OR RELEVANT HEALTH INFORMATION
PLEASE LIST DETAILS OF ANY SURGERIES YOU HAVE UNDERGONE AND DATE(S)
ARE YOU NOW SEEING OR IN THE PAST 7 YEARS HAVE YOU SEEN/CONSULTED WITH A CHIROPRACTOR?
- Yes
- No
ARE YOU NOW OR IN THE PAST 7 YEARS HAVE YOU SEEN/CONSULTED WITH A PSYCHIATRIST OR PSYCHOLOGIST?
- Yes
- No
FAMILY HISTORY
DOES EITHER PARENT OR ANY SIBLING HAVE A HISTORY OF CARDIOVASCULAR DISEASE WHICH WAS DIAGNOSED BEFORE AGE 70?
- Mother
- Father
- Sibling(s)
DOES EITHER PARENT OR ANY SIBLING HAVE A HISTORY OF CANCER WHICH WAS DIAGNOSED BEFORE AGE 70?
- Mother
- Father
- Sibling(s)
ARE YOU CONSIDERING REPLACING YOUR CURRENT INSURANCE POLICY?
- Yes
- No
HAVE YOU HAD YOUR DRIVER’S LICENSE SUSPENDED OR REVOKED OR HAD MORE THAN ONE TICKET OR ACCIDENT IN THE PAST 5 YEARS?
- Yes
- No
PLEASE LIST ANY ADDITIONAL INFORMATION YOU FEEL MIGHT BE HELPFUL TO US IN QUOTING YOUR INSURANCE
Who were you referred by?
Relationship To You

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