Fillable Employee and Family Medical Questionnaire (Arizona)

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Employee and Family Medical Questionnaire (Arizona)

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Employee and Family Medical Questionnaire
Section 1: Employer/Employee Information
Employer Name: ___________________________________________________________________________________________
Section 2: Family Health History
Within the past five (5) years has a physician or other licensed healthcare practitioner (“practitioner”) diagnosed or treated you or
anyone in your family applying for coverage, or is anyone currently getting treatment? Use an “X” to mark “YES” or “NO” in the boxes
heading each category of conditions below and mark with an “X” any of the following conditions that apply.
For all “YES” answers and conditions that you mark with an “X”, provide details in the table on the next page.
A. Heart/Circulatory YES NO D. Cancer/Tumors YES NO H. Bones/Muscles/Joints YES NO
A1. Anemia D1. Brain H1. Bulging/Herniated Disk
A2. Angina D2. Breast H2. Carpal Tunnel Syndrome
A3. Angioplasty/Stent D3. Colon H3. Fibromyalgia/CFS
A4. Aneurysm D4. Cyst H4. Fractures (Open or Closed)
A5. Blood Clots D5. Hodgkin's Disease H5. Gout
A6. Blood Disorder D6. Leukemia H6. Joint Replacement(Type:________)
A7. Bypass D7. Liver H7. Knee
A8. Cardiac Arrhythmia D8. Lung H8. Muscular Dystrophy
A9. Chest Pain D9. Lymphoma H9. Neck/Back
A10. Congestive Heart Failure D10. Melanoma H10. Shoulder
A11. Coronary Heart Disease D11. Ovarian H11. Spina Bifida
A12. Heart Murmur D12. Pituitary H12. Sprain/Strain
A13. Hemophilia D13. Prostate H13. Other (___________________)
A14. High/Low Blood Pressure D14. Stomach
I. Psychological YES NO
A15. High Cholesterol D15. Testicular I1. ADD/ADHD
A16. Pacemaker D16. Thyroid I2. Alcoholism
A17. Palpitations D17. Other (___________________) I3. Anxiety
A18. Sickle Cell Anemia D18. Stage of Cancer if known_______ I4. Autism
A19. Stroke/TIA
E. Neurological YES NO
I5. Bipolar
A20. Varicose Veins E1. Alzheimer's Disease I6. Depression
A21. Ventricular Tachycardia E2. Cerebral Palsy I7. Drug Abuse
A22. Other (___________________) E3. Epilepsy I8. Eating Disorder
B. Eyes/Ears/Nose/Throat YES NO
E4. Head Injury I9. Schizophrenia
B1. Acoustic Neuroma E5. Migraines I10. Suicide Attempt
B2. Cataracts E6. Multiple Sclerosis I11. Other (___________________)
B3. Chronic Sinusitis E7. Neuritis
J. Diabetes/Endocrine YES NO
B4. Cleft Lip/Palate E8. Paralysis/Hemiplegia J1. Diabetes controlled by:
B5. Detached Retina E9. Parkinson's Disease a. Diet
B6. Deviated Septum E10. Seizures/Convulsions b. Oral Medication
B7. Ear Infections E11. Other (___________________) c. Insulin
B8. Glaucoma
F. Transplants YES NO
d. Other (_______________)
B9. Retinopathy F1. Pending J2. Adrenal Glands
B10. Other (___________________) F2. On Waiting List J3. Growth Hormones
C. Immune YES NO
F3. Completed Transplant J4. Hyperthyroidism/Hypothyroidism
C1. ALS F4. Bone Marrow J5. Other (___________________)
C2. AIDS F5. Stem Cell
K. Reproductive YES NO
C3. HIV+ F6. Organ (Type: ________________) K1. Breast Disorder
C4. Immuno Deficiency
G. Arthritis YES NO
K2. Endometriosis
C5. Lupus G1. Arthritis K3. Fibroids
C6. Psoriasis G2. Osteoarthritis K4. Menstrual Disorder
C7. Scleroderma G3. Rheumatoid Arthritis K5. Ovarian Cysts
C8. Other (___________________) G4. Other (___________________) K6. Other (___________________)
Names of Family Members
Applying for Coverage
Relationship Date of Birth Gender
Male/Female
Height Weight
Employee
Spouse
Dependent
Dependent
Dependent
(feet, inches)
(pounds)
Please answer the following questions for yourself and for anyone in your family applying for coverage:
1. YES NO Is anyone currently pregnant or an expectant parent?
Due date: ________________
Yes No a. Has the pregnancy been confirmed by a physician or practitioner?
Yes No b. Pregnancy complications?
Yes No c. Multiple births expected?
2.
YES NO
Is anyone currently, or in the past five years has anyone been, a patient in a hospital, clinic,
surgi-center, urgent care facility, or other medical facility as an inpatient or outpatient?
3.
YES NO
Does anyone currently use tobacco products, including cigarettes, pipes, cigars or chewing
tobacco?
4.
YES NO
Does anyone currently have, or in the past 12 months has anyone had, any of the following?
abnormal test or physical results pending test results
health condition, illness or injury that may require treatment or surgery
tests, treatment or surgery advised unexplained weight gain/loss or fatigue
Worker’s Compensation injury or illness condition not mentioned above in Section 2
Please use this table to explain any “YES” answers or items that you marked in Section 2. You may attach additional sheets.
Question
Number
Name Diagnosis/Treatment Diagnosis
Date
Treatment Status
Section 3: Family Medications
YES NO Are you or anyone in your family applying for coverage currently taking any medications (including “over the
counter” or “OTC” medicine) prescribed or recommended by a physician or practitioner?
If you answer “YES” to the question above, please use this table to explain. You may attach additional sheets.
Name Medicine Dosage &
Frequency of Use
Date
Prescribed
Date Last Taken
or Ongoing
Condition(s) Being
Taken For
PLEASE NOTE: If you leave out or misrepresent any information, the premium for your group coverage may change retroactive to the
date the policy became effective. You or your authorized agent is entitled to receive a copy of this form.
Employee Signature: ____________________________________________ Date Signed: _________________________
L. Lung/Respiratory YES NO M. Intestinal YES NO N. Liver/Kidney/Urinary YES NO
L1. Allergies M1. Acid Reflux/GERD N1. Bladder Disorder
L2. Asthma M2. Colitis/IBS N2. Cirrhosis
L3. COPD (On Oxygen? ________) M3. Colon Disorder N3. Gaucher's Disease
L4. Cystic Fibrosis M4. Crohn's Disease N4. Hepatitis (Type: ___________)
L5. Emphysema M5. Diverticulitis/Diverticulum N5. Jaundice
L6. Lung Disorder M6. Gallbladder N6. Kidney Disorder
L7. Pneumonia M7. Gastric Bypass N7. Kidney Stones
L8. Sarcoidosis M8. Hiatal Hernia/Reflux N8. Liver Disorder
L9. Sleep Apnea M9. Pancreatitis N9. Polycystic Kidney
L10. Tuberculosis M10. Ulcer N10. Prostate
L11. Valley Fever M11. Ulcerative Colitis N11. Renal Failure
L12. Other (___________________) M12. Other (___________________) N12. Other (___________________)
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Employee and Family Medical Questionnaire (Arizona)

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Completed 12 August 2020

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