Group DivisionGroup Division - HealthPlan ServicesApr 21, 2003 · 27. Musculoskeletal Disorders 28. Prostate 29. Psychiatric (any mental/nervous condition except anxiety/depression)

April 21, 2003April 21, 2003April 21, 2003April 21, 2003Page 1 Page 1 oPage 1 Page 1 o

Medical Questionnaires

Attached you will find an updated listing of available medical questionnaires. Theretotal of 34 questionnaires. 1 new, and 33 revised. The major changes are:

1. A new Circulatory Q: to be used for any circulatory problem not relating toHeart/Cardiac, or Stroke/Brain. Common uses for this questionnaire are: BloodPeripheral Vascular disease, Carotid (neck), or any other artery/vein blockage surgery.

2. The Asthma/Allergy Q, has been renamed: Respiratory Disorder Q to includeonly Asthma, Allergy, but also Bronchitis COPD (chronic obstructive pulmonarydisease), Emphysema, Sleep Apnea, and others.

3. All other questionnaires have been updated to include the statement:

Please be advised that you may be required to submit medical records if theinformation provided is determined to be inadequate or incomplete.

You can click on any individual descriptive listing, shown on the next page to selecprint the desired questionnaire.

Please start using these new questionnaires immediately.

_________________________________Yolanda Ramirez-Smart, Medical Underwriting.

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Trustmark INSURANCE COMPANY 400 Field Drive Lake Forest, IL 60045 Phone (847) 615-1500

List of available medical questionnaires.

1. Alcohol abuse2. Anxiety / Depression3. Arthritis4. Attention Deficit / Hyperactivity5. Back / Spine (includes- muscle sprain/spasm, disc/vertebra, sciatica, & scoliosis)6. Cancer / Cyst / Tumor7. Cardiac ( to be used only for Cardiac/Heart conditions)8. Cerebral Palsy9. Cholesterol10. Circulatory ( not to be used for Cardiac/Heart or Stroke/Brain disorders)11. Diabetic12. Digestive Disorder (includes- colitis, crohns, diverticulitis, irritable bowel, & ulcer)13. Drug14. Epilepsy / Seizure15. Esophagus16. Female17. Headache / Migraine18. Hepatitis19. Hernia20. Hypertension21. Kidney / Dialysis22. Kidney Stone23. Knee24. Liver25. Lupus26. Muscular Dystrophy / Multiple sclerosis27. Musculoskeletal Disorders28. Prostate29. Psychiatric (any mental/nervous condition except anxiety/depression)30. Respiratory31. Spina Bifida / Neural Tube Defects32. Stroke / Cerebrovascular ( to be used only for brain related conditions)33. Supplemental34. Thyroid 4-03

TrustmarkINSURANCE COMPANY 400 Field Drive

Lake Forest, IL 60045Phone (847) 615-1500

ALCOHOL ABUSE QUESTIONNAIRE

Group Name: ____________________________________________________________Employee Name: _________________________________________________________Dependent Name (if condition is for dependent): ________________________________

Age: __________ Height: __________ Weight: __________

1. When did you have your last alcoholic beverage? (Closest approximate date) ____________________________________________________________________

2. Quantity consumed & type of alcohol used per day/ week_____________________

3. Have you ever participated in an alcohol rehabilitation program? If “yes” provide name and location of treatment facility and date(s) of treatment).______________ ___________________________________________________________________

4. Was it an inpatient or outpatient program? For how long? _____________________ ____________________________________________________________________

5. List all past and current medications taken, include dosage and frequency._____________________________________________________________________________

6. Have you ever been a member of Alcoholics Anonymous? If yes, how long have you participated ?__________ Are you currently an active member? Y/N If “yes”, how often do you attend meetings? ________________________________________________

7. Has there been treatment for any other medical condition as a result of Alcohol misuse?Y/N If “Yes”, provide details. _____________________________________________

8. Have you had a relapse? If so, when and for how long?________________________

9. Any history of abnormal liver enzymes? If so, when and list specific enzymes, dateand lab results. _______________________________What treatment was received?_______________________________Have liver enzymes returned to normal? Y/N

10. If there is any history of drug abuse, please complete the drug questionnaire.

Please be advised that you may be required to submit medical records if the informationprovided is determined to be inadequate or incomplete.

Employee Signature:_________________________________ Date:_________________ 4-03



ANXIETY/DEPRESSION QUESTIONNAIRE

Group Name: ____________________________________________________________Employee Name: _________________________________________________________Dependent Name (if condition is for dependent)_________________________________

Age:_________ Height:__________ Weight:___________

1. Circle the medical condition that has been diagnosed. Anxiety or Depression. When did symptoms first begin?_______________Cause if known.____________________

_____________________________________________________________________

2. What problems or symptoms have been experienced with this condition, and the last time they occurred? _____________________________________________________

3. Any therapy & / or counseling? ____ How often (ex: 2x per week, 1x per month)? Date of last visit? _________________ Recommendation: _____________________

4. Any hospitalizations resulting from condition? ______ Dates of inpatient length of stay___________________ Dates of outpatient length of stay _____________________

5. List all past and current medications taken (for this and any other condition) include name, dosage and how often taken, specify last date of use. ______________________ ______________________________________________________________________

6. Any time lost from work/school, due to this condition? YES ______ NO ______ Provide dates: __________________________________________________________

7. Has suicide been threatened or attempted? ________ If yes, when? _________________

8. Any history of alcohol or drug abuse________ If yes, complete the appropriatequestionnaire(s)





ARTHRITIS QUESTIONNAIREGroup Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if condition is for dependent):_________________________________


1. Type of arthritis, actual diagnosis if known (i.e. rheumatoid, osteoarthritis, gouty, Degenerative, Reiter’s syndrome, etc.) _____________________________________ ____________________________________________________________________

2. Age at onset of disease?______________Date first diagnosed:__________________

3. Location of arthritis. Any decrease in motion, deformities, or disability? Pleaseexplain:__________________________________________________________________________________________________________________________________

4. Treatment: Past________________________________________________________ Current ______________________________________________________________

5. Medication therapy (steroids, gold, anti-inflammatory drugs). Name, dosage and frequency of medications _______________________________________________ ____________________________________________________________________ Length of treatment with these medications _________________________________ Anticipated duration____________________________________________________ Ever participated in any experimental drug program?__________________________ If so, when____________________ Name of medication_______________________ For how long__________________ Through what facility______________________

6. Is there any history of work being missed? __________ Explain ________________

7. Any fluid aspiration from your joints or surgical replacement of joints?____________ If so, explain details (date, location) _______________________________________ Any need for future surgery? _____________ If “yes”, what type _________________ Scheduled? _____ If “yes” when? __________________________________________





ATTENTION DEFICIT/HYPERACTIVITY QUESTIONNAIRE

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if condition is for dependent);_________________________________


1. Circle the diagnosis made by the physician, Attention Deficit, Hyperactivity.

2. When was diagnosis made? (Age & date)____________________________________

3. What medication is taken to control condition? Frequency? _____________________ ____________________________________________________________________

Any change in medications?____________ and/or amount taken ________________ (If so, describe when and what changes were made)___________________________

In regards to children: is this medication taken all year around or only during school year?__________________________________________________________

4. Has there been improvement as a result of the medication? ______________________

5. Any psychological counseling required? If so, when did it begin? _______________ Frequency of visits? ________ How much longer will it continue, if known? _______ Any history of violent behavior? Y/N If “yes”, provide details_________________ ____________________________________________________________________

6. Any hospitalization required? If so, When?_______________Where?_____________ ________________ How long?____________________________________________

7. What has the Doctor told you about prognosis of condition?______________________


Employee Signature_________________________________ Date________________ 4-03



BACK/SPINE QUESTIONNAIRE

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if condition is for dependent): ________________________________


1. Condition diagnosed? Muscle sprain/spasm, disc/vertebra disorder, sciatica, scoliosisof the spine, or other? __________________________________________________

2. When were you first diagnosed with a back problem? _________________________

3. What area of the back/spine is affected? Please specify if neck, upper back, lower back. If scoliosis of the spine, what is the degree of curvature ________________________

4. Symptoms experienced?_________________________________________________

5. Cause of condition (i.e. injury due to accident/work related or acute onset)_________ ____________________________________________________________________

6. a. Any physical therapy or chiropractic manipulation required?_________________ b. Duration?__________________________________________________________ c. Date released from MD? ______________________________________________

7. a. Any surgical intervention/hospitalization required? (If so, give date, procedure performed, and the results)? _____________________________________________ ____________________________________________________________________ b. Any further surgery or treatment required/recommended in the future? (If so, when and for what reason)?______________________________________________

8. Are you currently taking any medications? If yes, please provide the name, dosage, and frequency?________________________________________________________ ____________________________________________________________________

9. Any complications? Residuals? Limitations? Loss of mobility?______________ ____________________________________________________________________


Employee Signature__________________________________ Date_________________ 4-03



CANCER/CYST/TUMOR QUESTIONNAIRE



1. Must provide specific name (type), location, size, and stage. If unsure, ask your doctor._____________________________________________________________________

2. When was condition first diagnosed? _______________________________________

3. Surgery/treatment? (Date and description) One or more times? _________________ _____________________________________________________________________

4. Benign or malignant findings through pathology report? _______________________

5. Any metastasis? __________ If yes, where? _______________________________

6. Has there been any Chemotherapy/Radiation performed at any time? If so, number oftreatments? When was last one? __________________________________________

7. Are you taking any medications? If so, provide name, dosage and frequency? ________________________________________________________________________

8. How often do you return for checkups?______________ Date last seen and therecommendation. _____________________________________________________

9. Any complications / residuals?___________________________________________

10. Smoker Y/N, cigarettes/tobacco use per day? ____________ years used: __________If not currently using, how long ago did you quit? ___________________________

11. What has your doctor told you about the outlook/prognosis?_____________________





CARDIAC QUESTIONNAIRE

Group Name: _____________________________________________________________Employee Name: __________________________________________________________Dependent Name (if condition is for dependent): _________________________________

Age:___________ Height___________ Weight:____________

Smoker: Y/N Cigarette/tobacco product per day:_________ Length of time used_______If not currently using tobacco products, how long ago did you quit? __________________

1. Diagnosis of heart disorder? (i.e. Mitral Valve Prolapse, murmur, heart attack, congenital abnormality, arrhythmia, Coronary Artery Disease etc.) _________________________

2. Any current symptoms? (i.e. chest pain, palpitations, shortness of breath, rapid pulse rate, etc.) _____________________________________________________________

3. When diagnosed?____________ Tests performed and results:__________________ ____________________________________________________________________

4. Treatment and date received, include any hospitalizations, surgeries? _____________ ____________________________________________________________________

5. Name, dosage and frequency of all medications prescribed. Still taking medications? If not, when stopped? ___________________________________________________ _____________________________________________________________________

6. Any elevated cholesterol or triglycerides? If yes, date of test and results, and current treatment or complete the Cholesterol questionnaire. __________________________

7. Any future testing/surgery/treatment required or recommended? If so, provide details. _____________________________________________________________________

8. Date last seen for cardiac evaluation? Results? _______________________________

9. If you had Angioplasty and/or Bypass surgery, how many vessels were done? _______


Employee Signature:____________________________ Date:______________________ 4-03



CEREBRAL PALSY MEDICAL QUESTIONNAIRE



1. When was condition originally diagnosed? ___________________________________ _____________________________________________________________________

2. Are there any physical disabilities? _____ If yes, what are they? _______________ _____________________________________________________________________

3. Is there any mental incapacity associated with this condition? ___________________

4. What problems or symptoms have been experienced with this condition? _________ ___________________________ Last time it happened? ______________________

5. What treatment was received and when? Include any surgery, hospitalization or medication ? (how often and what amount)__________________________________ _____________________________________________________________________

6. How often does the person visit the doctor’s office or medical clinic for this condition? ____________________ Date of last visit ___________________________________

7. Any physical/speech therapy? If yes, what is the schedule? _______________________

8. Have any future tests, surgery or treatment been scheduled, prescribed or recommended? If yes, please explain.____________________________________________________

9. Have there been any complications such as incontinence, difficulty with feeding,swallowing, or wheelchair dependent etc.? __________________________________





CHOLESTEROL QUESTIONNAIRE

Group Name: ____________________________________________________________Employee Name: _________________________________________________________Dependent Name (if condition is for dependent)_________________________________

Age: __________ Height: _________ Weight: _______

1. When was condition first diagnosed? ______________________________________

2. Please circle all that apply. Do you smoke, have High Blood pressure, Diabetes or family history of Coronary Heart Disease. Other medical conditions? _____________

_____________________________________________________________________

3. What problems or symptoms have been experienced with this condition (i.e. Chest Pain,activity intolerance)? ___________________________________________________

4. Date of last test and results for cholesterol, triglycerides, HDL, LDL and, Cholesterol /HDL ratio? These lab results MUST be provided, if unsure, please call your doctor._____________________________________________________________________

5. What treatment was received and when? Include any surgery, hospital stays ormedication. Please state medication(s), dosage taken, and frequency, per day.______________________________________________________________________

6. How often does the person visit the doctor’s office or medical clinic for this condition?When was the last time and what was the result? ___________________________________________________________________________________________________________________

7. Have any future tests, surgery or treatment been scheduled, prescribed or recommended?___________ If yes, please explain: _______________________________________





CIRCULATORY DISORDER QUESTIONNAIRE (DO NOT USE THIS FORM FOR HEART OR STROKE/BRAIN DISORDERS)



1. What is the Circulatory condition(s) that has been diagnosed? Thrombosis(blood clot),Peripheral vascular disease, intermittent claudication, carotid artery (neck) blockage, artery blockage of arms, legs, or trunk of body, gangrene, Aneurysm not located in the brain, other? ______________________________________________________

2. Name the specific artery(s) or vein(s) affected. _______________________________If condition is caused by blockage, what percentage (i.e. 20%, 50% ) ______________

3. What problems or symptoms have been experienced with this condition? _________________________________________________________________________________

4. Provide details for any test or surgery done (i.e. Angioplasty, Aortofemoral bypass, endarterectomy, amputation etc.) ___________________________________________

5. Date of last Doctor visit. _____________________ What was the recommendation? ________________________________________________________________________

6. Have any future tests, treatment, or surgery been prescribed? Y/N If “YES”, provideDetails. _______________________________________________________________

7. List all medication(s) you are taking for this or any other condition. _____________ ____________________________________________________________________

8. If you are being treated for any other medical condition, please provide details. _______________________________________________________________________

9. Have you ever or are you currently using any form of tobacco? Y/N Quit date? _____


Employee Signature________________________________________ Date____________ 4-03



DIABETIC QUESTIONNAIRE



1. Date diabetes was first diagnosed?________ Age at diagnosis?________

2. Do you follow a diabetic diet? ____________________________________________

3. Are you receiving oral medication or insulin? Give name(s) and dosage(s). ______________________________________________________________________________

4. Do you test your blood sugar yourself? YES/NO. If YES, please provide the last three (3)readings, include the date and specific glucose reading.1st.date:_________reading:________ 2nd date:________reading :________3rd.date:_________reading:________

5. If you do not check your own blood sugar, please provide the last two (2) fasting bloodsugar results from your Dr.’s office, include the date done and the specific glucosereading. 1st.date:_________ reading_______ 2nd.date:________ reading:_________

6. Date and reading of Hgb A1C (Glycohemoglobin). This lab result MUST be provided, ifunsure, please call your doctor to ask. Date:____________reading:______________

7. Any problems / complications resulting from diabetes (i.e. neuropathy, gangrene, oramputation)? __________________________________________________________

8. Are you currently being treated for any other condition besides diabetes? If yes, please list. __________________________________________________________________


Employee Signature:____________________________________ Date:_________________ 4-03



DIGESTIVE DISORDER QUESTIONNAIRE

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if condition is for dependent):_________________________________


1. What is the condition that has been diagnosed? Colitis(ulcerative or non-ulcerative) diverticulitis, Gastritis, irritable bowel syndrome, Crohn’s ulcer (specify which type) other? _____________________Cause, if known: __________________________

2. Date of first symptoms __________ Date of most recent symptoms ____________How often do symptoms occur?__________________________________________

3. Have any tests been done? YES / NO. If yes, give the name of the test, date doneand results (i.e. Barium tests, scopes, x-rays etc). ____________________________

____________________________________________________________________

4. What treatment was received and when? Include and list all medications, withdosages, and frequency. Hospitalization & / or surgery. ______________________

___________________________________________________________________

5. Have future tests, treatments, or surgery been recommended, prescribed orscheduled? When?_____________________________________________________

6. Does this person have a colostomy? YES / NO Temporary? ____ Permanent? _____

7. Are you being treated for any other medical condition? If “YES”, provide details._________________________________ _____________________________________





DRUG QUESTIONNAIRE



1. List names of all substances/drugs used, either in the past, or currently using, includingalcohol. ______________________________________________________________

2. Provide the dates for the amount, frequency and length of abuse, including the last dateused. _________________________________________________________________

Multiple drug abuse?_______ Alcohol abuse?________ If yes, complete appropriate questionnaire. Date last used _____________________________________________

3. Have you ever participated in a drug/chemical dependency program? _____________ Voluntarily or involuntarily? _____________________________________________

4. Inpatient or outpatient program? _______ Length of treatment__________________

5. Any relapses/re-use of substances/drugs? ________ If so, explain when __________ ___________________________________________________________________

6. Any history of psychiatric counseling? ________ When? _____________________ Frequency, date of last visit ____________________________________________

Any medication taken? _________ Name, dosage, frequency and date last taken___________________________________________________________________

7. Do you belong to a support group? If so, how often are you in attendance?________

8. Are you currently being treated for any other medical condition, whether related to drugs or not. If “YES”, provide details. ___________________________________________ Ever tried to commit suicide? Y/N When?____________________________________

9. Have you ever been treated for any medical condition attributed to drug abuse? (i.e. heart arrhythmia, Hepatitis, seizures, HIV, Mental illness, or chronic cough)? If “YES”, when and provide details __________________________________________


Employee Signature_________________________________ Date__________________ 4-03



EPILEPSY/SEIZURE QUESTIONNAIRE



1 Type of seizures Grand mal, focal, febrile petit, other (exact type MUST be provided)._____________________________________________________________________

2. Date of first seizure__________________Date of last seizure____________________

3. Frequency and length of seizures___________________________________________

Describe the nature of the attacks. __________________________________________

4. Has any cause for seizures ever been given? (i.e. injury, alcohol/drug, related to infection, genetic disorder or brain tumor/aneurysm)___________________________________

Provide names, dates & results of tests/scans. ________________________________

5. Are you now on or ever been on medication? _________ If so, when? ____________

Provide name, dosage and duration of medication(s). ___________________________ ______________________________________________________________________

6. Any driving restrictions or other limitations as a result of the seizures? If yes. Pleasespecify______________________________________________________________

7. How often is a doctor seen for this condition? ___________ When was your last visit andwhat was the recommendation? _____________________________________________


Employee Signature___________________________________ Date_______________ 4-03



ESOPHAGUS MEDICAL QUESTIONNAIRE

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if condition is for dependent):_________________________________ Height_________ Weight___________

1. What is the specific medical condition(s) that has been diagnosed (i.e. Acid Reflux,Esophageal Stenosis, other)? When did it begin? ____________________________

2. Cause, if known? _____________________________________________________

3. What problems or symptoms have been experienced with this condition? Last time it happened?_________________________________________________

4. What treatment was received and when? Include any surgery, hospital stays ormedication(s) (dosage and frequency). _____________________________________ ___________________________________________________________________

5. How often does the person visit the doctor’s office or medical clinic for this condition?When was the last time and what was the result? _______________________________________________________________________________________________

6. Have any endoscopies or biopsies been performed? Provide the date and results.___________________________________________________________________

7. Can they swallow / eat? YES / NO. If no, do they have a feeding tube?Temporary?________________ Permanent?___________________

8. Have any future tests, surgery or treatment been scheduled, prescribed orrecommended? ___________ If yes, please explain. ___________________________________________________________________________________________





FEMALE DISORDERS

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if condition is for dependent ): ________________________________


1. Specific diagnosis if known (endometriosis, abnormal pap, irregular bleeding, uterine fibroids, other). ______________________________________________________

2. Date of onset? ________________Cause if known___________________________

3. Symptoms experienced and last time they occurred? __________________________

4. Type of treatment/surgery received and when (D&C, Hysterectomy, other) _______ ___________________________________________________________________

5. Please list all medications currently being taken, and the dosage. _______________ ___________________________________________________________________

6. Any history of abnormal pap test? Y/N. If “YES”, what class (I, II, III, IV)? TheSpecific class MUST be provided. If unsure, ask your doctor. _________________

7. How often do you go to the Dr. for follow-up? ____________________________ Date and result of most recent follow up pap test. ___________________________

8. Any suspicion of malignancy? _____________ If “YES”, where? ________________

9. Any complications or ongoing symptoms? If “YES”, provide details. ________________________________________________________________________________

10. Date of last mammogram?_______________________________________________

11. Are you being treated for any other medical conditions? If “YES”, provide details._____________________________________________________________________


Employee Signature___________________________________ Date________________ 4-03



HEADACHE / MIGRAINE QUESTIONNAIRE



1. What type of headaches do you suffer from (Cluster, Migraine, Sinus, or other)? ____________________________________________________________________

2. Any cause determined for them (i.e. stress, allergy related, brain lesion)?__________

____________________________________________________________________

3. Length of time you have had these headaches? Frequency? How long do they last? Incapacitating/disabling?________________________________________________

____________________________________________________________________

4. When first diagnosed? How diagnosed?_____________________________________

5. Special testing done (EEG, Cat Scan, MRI, X-rays, Physical)? Results of testing____

_____________________________________________________________________

6. Treatment to date______________________________________________________

____________________________________________________________________

7. Medications? (Name, dosage & frequency)__________________________________

____________________________________________________________________


Employee Signature_____________________________________ Date______________ 4-03



HEPATITIS

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent name (if condition is for dependent): _________________________________ Age_________ Height___________ Weight_____________

1. Type if known? (A, B, C, Alcoholic, Chronic)________________________________

2. Any cause known? _______________________ Date of onset? __________________

3 How often are liver function tests done ? _____________ Date and results of most recent liver function enzymes:____________________________________________

4. Any history of abnormal findings? Y/N If “yes”, when and what treatment was received? _____________________________________________________________________

5. How often do you see the Dr. for a follow-up? ________________________________

6. Date of last visit to Dr.? ________Recommendations?__________________________

7. Are you currently taking any medications? (Name, dosage & frequency) _________ _____________________________________________________________________ _____________________________________________________________________

8. Do you expect to be, or are you on a waiting list for a liver transplant? YES / NO If you are currently waiting, how long have you been on the list?_________________

12. Are you being treated for any other medical condition? If “yes”, name condition andtreatment:____________________________________________________________





HERNIA QUESTIONNAIRE

Group Name:____________________________________________________________Employee Name:__________________________________________________________Dependent Name(if condition is for dependent): ________________________________ Age: __________ Height: __________ Weight: __________

1. Location - (abdominal, esophageal)________________________________________

2. Type (hiatal, inguinal, epigastric, etc.)______________________________________

3. Any surgery performed or expected? _______________ When? __________________

_____________________________________________________________________

4. Any prior occurrence of hernia?________________________ When?_____________

_____________________________________________________________________

5. Are you currently taking any medications? (Name, dosage & frequency) _________

_____________________________________________________________________

_____________________________________________________________________


Employee Signature___________________________________ Date________________ 4-03



HYPERTENSION QUESTIONNAIRE

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if condition is for dependent): ________________________________ Age____________ Height____________ Weight____________

1. Date Hypertension was first diagnosed: _____________________________________

2 Type of treatment? (diet, exercise, and medication(s)? ________________________

Current medications and daily dosages:_____________________________________

Has there been a change to your current medications/dosages in the past six months? If so, how has it changed?__________________________________________________

3. Date physician was last seen:___________Recommendation?___________________

a. Frequency of visits:__________________________________________________

b. 3 blood Pressure readings from 3 separate dates, within the past 6 months, readings canbe from Dr.’s Office, home, pharmacy etc. Dates and B/P readings must be provided.

1st date & B/P reading__________________________2nd date & B/P reading__________________________

3rd date & B/P reading__________________________ c. Average over past year:_______________________________________________

4. Are you currently pregnant? ______________ Date due: _____________________

5. Are you currently smoking, or using any forms of tobacco? ____________________

6. Any history of Stroke, Diabetes, Kidney or Heart related conditions?______ If so, complete the appropriate questionnaire(s).7. Have any abnormalities ( protein, blood, etc) ever been found in your urine? Y/N If

“YES”, provide details. __________________________________________________


Employee Signature_______________________________ Date____________________ 4-03



KIDNEY/DIALYSIS QUESTIONNAIRE

Group Name:___________________________________________________________Employee Name:________________________________________________________Dependent Name:(if condition is for a dependent)______________________________ Age:___________ Height:_________ Weight:_____________

1. What is the specific medical condition(s) that has been diagnosed?______________When did symptoms begin?________________Cause?________________________

2. What problems or symptoms have been experienced with this condition?____________________________________________________________________________Last time they occurred?______________________________________________

3. What treatment was received and when ( include any surgery, hospital stays, tests andmedications with name, dosage, and frequency)?____________________________

____________________________________________________________________

4. How often do you visit the Dr.’s office or clinic for this condition?_______________When was the last visit and the recommendation?____________________________

5. Have you, or are you currently receiving Dialysis? YES/ NO. If yes, what type ofdialysis do you receive? Hemodialysis, Peritoneal dialysis, other?______________How often do you receive dialysis treatment(s) per week? _____________________

6. What future tests, surgery, or treatment have been recommended?__________________________________________________________________________________

7. Do you expect to be, or are you on a waiting list for a kidney transplant? YES / NOIf you are currently on the Transplant list, how long have you been waiting? ______

8. Are you being treated for any other medical condition Y/N. If “YES”, provide details.____________________________________________________________________





KIDNEY STONE QUESTIONNAIRE



1. When did your symptoms begin? _________________________________________

2. Was this your first episode or is this recurrent? _______________________________- If recurrent, please provides dates of all episodes ___________________________________________________________________________________________

3. How treated for this episode? _____ passed on own _____ surgical removal

_____ lithotripsy

4. If more than 1 episode, list all methods of treatment. __________________________ _____________________________________________________________________

5. Was a x-ray done to determine if any stones are still remaining? If so, when and results?______________________________________________________________

6. Are you taking any medication? - If so, indicate name and frequency? _____________________________________ ____________________________________________________________________

7. Date last seen for a follow up? Results? ___________________________________ ____________________________________________________________________





KNEE DISORDERS

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent name (if condition is for dependent): _________________________________


1. Type of injury (i.e. Torn ACL, dislocated knee cap, other)_________________________________________________________________________________________

2. Treatment received? ____________________________________________________

3. Any physical therapy? When? How frequent? When released? _________________ _____________________________________________________________________

4. Any restrictions of movement or disability? Y/N. If “YES”, provide details. ___________________________________________________________________________

5. Any surgery? Type? When? _________________________________________________________________________________________________________________

6. Any pins or rods? ______________________________________________________

7. Have they removed the pins or rods? _______________________________________- If not, when is the proposed date? _____________________________________

8. Are you currently taking any medications, for any condition? If so, please give name, dosage and frequency: ___________________________________________________

____________________________________________________________________





LIVER MEDICAL QUESTIONNAIRE

Group Name: _________________________________________________________Employee Name: ______________________________________________________Dependent Name (if condition is for dependent): _____________________________

Age: __________ Height: __________ Weight: _________

1. What specific medical condition(s) has been diagnosed? ___________________When did it begin? __________________Cause?__________________________

2. What symptoms occurred? Any currently? _______________________________

3. Any history of abnormal liver enzymes? If so, when and what type of treatment was received? __________________________________________________________ Have the enzymes returned to normal? Y/N . How often are labs done? ___________ Last date and results?_________________ __________________________________________________________________

4. What treatment was received and when? Include any surgery, hospital stays or medication (dosages and frequency)_____________________________ ________________________________________________________________

5. Any history of, or are you now consuming alcohol? Y/N If “yes”, Have you ever participated in an alcohol rehabilitation program? When? __________________

6. List any/all medical conditions you are being treated for. ___________________

7. Are you a candidate for a future liver transplant? ________ If so, how longhave you been on the waiting list? ______________________________________

8. Have any future tests, surgery or treatment been scheduled, prescribed or recommended? If yes, please explain: ____________________________________


Employee Signature_______________________________ Date___________________ 4-03



LUPUS QUESTIONNAIRE



1. What type of lupus do you have? (i.e. systemic lupus [SLE], discoid lupus, [DLE])___________________________________________________________________

2. When was lupus diagnosed? _____________________________________________

3. What tests have been performed? What were the results? __________________________________________________________________________________________

4. What medications have / do you take? Please list names, dosages and dates taken. ___________________________________________________________________

5. Do you have symptoms while taking medications? ___________________________ ___________________________________________________________________

6. If you are in remission, when did remission begin? ___________________________

7. Have you had multiple remissions? If so, when? How long?___________________ ____________________________________________________________________

8. Do you take medications while in remission? ______________________________

9. Has there been damage to any other organ(s) (i.e. Kidneys, Nervous system, Digestivesystem etc.)? Y/N. If “YES”, provide details. _______________________________





MUSCULAR DYSTROPHY /MULTIPLE SCLEROSISQUESTIONNAIRE

Group Name: ______________________________________________________________Employee Name: ___________________________________________________________Dependent Name (if condition is for dependent): __________________________________

Age: __________ Height: __________ Weight: _________

1. Is the diagnosis Muscular Dystrophy or Multiple Sclerosis? _______________________If Muscular dystrophy, is it: Duchenne, Facioscapulohumeral, Distal myotonic, LimbGirdle, or other?__________________________________________________________

2. What problems or symptoms have been experienced with this condition (i.e. vision disturbances, tremors, muscle weakness or paralysis etc.)? List specific muscles affected. ________________________________________________________________________

3. What tests have been done? Give name of test, date and result: ___________________________________________________________________________________________

4. What type of treatment was received, either past or present. Include any physical therapy,surgery, hospital stays etc.__________________________________________________

5. List all past and current medications taken (include dosage and frequency).________________________________________________________________________________________________________________________________________________

6. How often does the person visit the doctor’s office or medical clinic for this condition?When was the last visit and what was the recommendation? ______________________________________________________________________________________________

7. Please list any disability or limitations from disease. ____________________________ Can the person with the condition provide his or her own daily care? YES____ NO____

8. Have future tests, surgery or treatment been scheduled, prescribed or recommended? ____If yes, please explain: ______________________________________________________





MUSCULOSKELETAL DISORDER QUESTIONNAIRE



1. Name of condition diagnosed_________________ Date of onset ________________

2. What were the symptoms experienced? ________________________________________________________________________________________________________

3. Location? ___________________________________________________________

4. Any physical therapy required? If so, when? How long was/is therapy required?___________________________________________________________________

5. Any surgery anticipated or already performed? If so, what type? When?______________________________________________________________________________________________________________________________________

6. Any restrictions of movement? _________________________________________

7. Any permanent disability? _____________________________________________

8. Are you currently taking any medications? If so, please provide name,dosage and frequency: ________________________________________________ __________________________________________________________________

9. Are you being treated for any other medical condition?______ If so, please list them:___________________________________________________________________





PROSTATE QUESTIONNAIRE



1. Name of prostate disorder. _______________________________________________If diagnosis was cancer, what stage? _______________________________________Age at diagnosis. _______________________________________________________

2. What are symptoms? (i.e. night time voiding, difficulty voiding) _____________________________________________________________________________________

3. Was a prostate biopsy done? Y/N When? __________________________________Results. ______________________________________________________________

4. Are you currently taking medications, or undergoing any form of treatment or therapy?If yes, give details.___________________________________________________________________________________________________________________________

5. Have any future tests, surgery or treatment been scheduled, prescribed or recommended?If yes, give details. _____________________________________________________ ____________________________________________________________________

6. Was PSA (Prostate specific antigen) done? If so, please give the date and the level.____________________________________________________________________





PSYCHIATRIC QUESTIONNAIRE

Group Name:____________________________________________________________Employee Name:_________________________________________________________Dependent Name: (if condition is for dependent): _______________________________


1. Name of specific diagnosis _____________________________________________

2. What symptoms were experienced, when did they begin?_______________________

Any current symptoms?______ If “yes”, describe____________________________

3. Date therapy began?_______________ Frequency of visits? ____________________

4. Date last seen for therapy/counseling?______________________________________

5. Any hospitalization? If so, when? _________________________________________

Provide dates of inpatient length of stay. ____________________________________

Provide dates of outpatient treatment. ______________________________________

6. Any time lost from work due to psychiatric illness?_________ If yes, when and how long?______________________ Returned to work full time?___________________

7. Has suicide ever been attempted or threatened? If yes, when. ___________________

8. List all medications (include dosage, frequency and last date taken).___________________________________________________________________________________

9. Any history of alcohol or drug abuse? If yes, complete the appropriate questionnaire.List any other condition(s) you are being treated for:_________________________





RESPIRATORY DISORDER QUESTIONNAIRE

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if condition is for dependent) _________________________________


1. Circle the Respiratory disorder: Allergies Asthma Bronchitis COPD Emphysema Sleep Apnea Other (please be specific)________________________________________________ What is the degree of severity? mild moderate severe

2. Date of onset:_____________ What symptoms do/did you have? _________________Do your symptoms restrict your activity? Y/N If “YES”, please describe ______________________________________________________________________________

3. Date of last Doctor visit:__________________ Frequency of visits:_______________

4. Names and dosages of medication used:_____________________________________ _____________________________________________________________________ Name of Inhaler__________________ Number of puffs/day____________________ Name of Shots___________________ Frequency ____________________________

5. Is oxygen used? Y/N If “YES”, is it used as needed or continuously?_____________ Is a CPAP(continuous positive airway pressure) or PEEP(positive end-expiratory pressure) Machine used? Y/N If “YES”, how often ___________________________________

6. Has any work/school been missed? Y/N If “YES” how long and when? ___________

7. Number of attacks per year:___________________ Last one: ___________________

5. Any hospitalizations due to this condition? Y/N. If “YES”, give dates and duration of eachoccurrence. _______________________________________________________________

6. Have you ever, or do you currently use any tobacco products, including cigarettes, cigars, chew etc.? Y/N. If yes, length of time used?___________________________

If not currently using, how long ago did you quit?_____________________________





SPINA BIFIDA/NEURAL TUBE DEFECTS QUESTIONNAIRE

Group Name: _________________________________________________ Employee Name:_______________________________________________ Dependent Name (if condition is for dependent)______________________________

Age: _____ Height: _____ Weight: _____

1. Name of condition.____________________________________________________

2. Is there any physical disability or mental retardation? _______ If “yes” explain:

_________________________________________________________________________________

3. Is there any hydrocephalus (water on the brain)? _______ If yes, was a shunt placed? __________ Is the shunt still in place?____________ Functioning?_____________

4. Is there any anencephaly? ________ If yes, is the brain partially/ completely absent?____________________________________________________________________

5. Have any tests been done? _____ If yes provide type of test, date, and results.____________________________________________________________________

6. What treatment(s) was received and when? Include any surgery, hospital stays or medication.___________________________________________________________

7. How often does the person visit the doctor’s office or medical clinic for this condition?When was the last time and what was the result? _________________________________________________________________________________________________

8. Have future tests, surgery or treatment been scheduled, prescribed or recommended?_____ If yes, please explain: ____________________________________________





STROKE / CEREBROVASCULAR QUESTIONNAIRE

Group Name:_____________________________________________________________Employee Name:__________________________________________________________Dependent Name (if dependent has condition)___________________________________Age: _________ Height: __________ Weight: __________ Smoker? _________

1. What condition has been diagnosed? TIA (mini stroke) stroke, aneurysm (state location)?What type: subdural, epidural, cerebral, subarachnoid, intracerebral, other? _________

______________ Was it caused by bleed, blood clot, other? ____________________

2. Age at diagnosis? ____________Recurrences? When?__________________________

3. What treatment was received and when? Include any surgery, medication(s) ( include dosage and frequency) or hospitalizations._________________________________ ______________________________________________________________________

4. Have any tests been done? ___________ If yes, give test name, date and result: _____________________________________________________________________

5. What problems or symptoms/complications have been experienced with this condition? (i.e. paralysis, difficulty with speech, or swallowing) _________________ ____________________________________________________________________

6. How often does the person visit the doctor’s office or medical clinic for thiscondition? When was the last time seen and what was the result? ___________________________________________________________________________________

7. Have any future tests, surgery or treatment been scheduled, prescribed or recommended? _________. If yes, please explain: ______________________________________

8. Is this person able to care for themselves with activities of daily living (i.e. dressing, bathing / showering, feeding self)? If no, explain. ____________________________





SUPPLEMENTAL MEDICAL QUESTIONNAIRE



1. What is the medical condition(s) that has been diagnosed? _____________________ Location? ______________________ When did it begin?_____________________

2. Cause, if known?______________________________________________________

3. What problems or symptoms have been experienced with this condition? Last time ithappened? ___________________________________________________________

4. Have any tests been done? _____ If yes, give test, date and results: __________________________________________________________________________________

5. How often does the person visit the doctor’s office or medical clinic for this condition?When was the last time and what was the result? _____________________________

6. Have future tests, surgery, treatment, counseling been recommended or prescribed?If so, please explain.____________________________________________________

7. Have you ever, or are you currently taking any medication for this or any other condition?If “yes”, list medication, and what condition it is being taken for:__________________________________________________________________________________________





THYROID DISORDERS


Age: ___________ Height: __________ Weight: __________

1. Name of specific diagnosis? _____________________________________________

2. Overactive ( __ ) Underactive ( __ )

3. Symptoms experienced? ________________________________________________

4. Goiter present? _______________________________________________________

5. Any suspicion or history of malignancy? ___________________________________

6. Name and daily dosage of all medications currently being taken? _____________________________________________________________________________________

7. Types and date of treatment received? ___________________________________________________________________________________________________________

8. Ever hospitalized for this? _______________________________________________

9. Why? When? ________________________________________________________

10. Any surgery done? Expected? ___________________________________________

11. When? Why? ________________________________________________________



Documents

Group DivisionGroup Division - HealthPlan ServicesApr 21, 2003 · 27. Musculoskeletal Disorders 28. Prostate 29. Psychiatric (any mental/nervous condition except anxiety/depression)