Preliminary Health Questions

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– Step 1 of 4

Legal Name (as it appears on state license) *

First

Last

Email *

Date of Birth *

Phone Number *

Residential State *

Residential Zip Code *

Tobacco User?

YES
NO

Is the applicant, spouse/domestic partner/significant other, dependent children, or any other member of their household currently being treated for, or expect to be treated for any of the following over the next 12 months?

Organ failure, leading to bone marrow or organ transplant *

Any genetic condition that requires cell or gene therapy treatments? *

YES
NO

Any cancer that requires chemotherapy, radiation, bone marrow treatments, and/or cell therapy treatments? *

YES
NO

Kidney failure requiring dialysis treatments? *

YES
NO

Hemophilia, or other blood clotting disorders? *

YES
NO

Inpatient Mental Health and/or Substance or Alcohol Treatment *

YES
NO

Has the applicant, spouse/partner, significant other, or dependent children been seen by a medical provider, had recommended treatment, received care (including prescriptions), or been hospitalized for any of the following within the last 5 years? This included any current treatment/medications/prescriptions.

Cancer (any kind, this includes skin cancer) *

YES
NO

Heart Disease (such as, but not limited to, heart surgery, including bypass surgery/CABG, heart attack, stroke, heart failure (do not include high blood pressure) *

YES
NO

Home Bound, incapacitated or incapable of carrying out daily activities (such as dressing, bathing, or feeding) *

YES
NO

Autoimmune or blood disease (Please see link below for disease examples)

YES
NO

Autoimmune and Blood Disease Examples

Organ failure/transplant for Kidney, Liver, Lung, or Heart *

YES
NO

Organ support, such as dialysis or ECMO *

YES
NO

Pregnant, expecting or receiving treatment to become pregnant *

YES
NO

Hospitalized currently or in the past 5 years (this includes skilled nursing, mental health, substance treatment and rehabilitation facilities) *

YES
NO

Respiratory Disorders, such as COPD, emphysema, chronic bronchitis or chronic pneumonia *

YES
NO

Musculoskeletal Disorders, such as sciatica, osteoporosis, cervical/neck/back disorder (including any type of injection or procedure), Muscular Dystrophy, Cerebal Palsy, dermatomyositis, compartment syndrome *

YES
NO

Substance Abuse or Dependency (including but not limited to alcohol, cocaine, meth, heroin, opioids) *

YES
NO

Type 1 Diabetes *

YES
NO

Major Surgery (see reference link below for examples of but not limited to) in the past 5 years or any planned or recommended surgeries in the next 12 months *