Secure Investors Group INC
Health Questionnaire

Health Questionnaire

These questions help us see whether you are likely to qualify for a Medicare Supplement plan before you apply. It takes about 10 minutes.

Your privacy: This form does not ask for your name, date of birth, phone, email, or address. Your answers are matched to you only by the private code we emailed you. Please do not type your name or any other personal details anywhere on this form.

1 Your private code

It looks like SIG- followed by 6 letters and numbers. If you opened this page from our email link, it’s already filled in.

2 Your Medicare situation

When did (or will) your Medicare Part B start?
What coverage do you have now (besides Original Medicare)?
Is any of the following happening to your current coverage? (Check all that apply)

3 Right now

Answer about your situation today.

1. Are you in a hospital, nursing home, assisted living facility, or hospice, or receiving home health care?
2. Do you need help with daily activities (bathing, dressing, eating, walking), use a wheelchair or motorized scooter, or stay in bed most of the day?
3. Are you receiving physical, occupational, or speech therapy?
4. Has a doctor recommended a test, treatment, surgery (including cataract surgery or joint replacement), or follow-up visit that you have not had yet? (Routine screenings don’t count.)
5. In the last 60 days, has a doctor recommended that you be hospitalized, move into a nursing or assisted living facility, or receive home health care?
6. In the last 12 months, have you been hospitalized or visited the emergency room 2 or more times?

4 Have you ever been diagnosed with or treated for…

Answer about any time in your life.

7. Diabetes that needs 3 or more medications, or more than 50 units of insulin a day — or diabetes along with heart or circulation problems, kidney disease, nerve damage (neuropathy), eye damage (retinopathy), skin ulcers, diabetic coma, or insulin shock?
8. Alzheimer’s disease, dementia, or mild cognitive impairment (memory loss)?
9. Parkinson’s disease, ALS, multiple sclerosis, myasthenia gravis, muscular dystrophy, or Huntington’s disease?
10. HIV or AIDS?
11. An organ, bone marrow, or stem cell transplant? (Cornea transplants don’t count.)
12. An implanted cardiac defibrillator?
13. Cancer that spread to another part of the body or came back after treatment? (Basal or squamous cell skin cancers don’t count.)
14. High blood pressure that needs 3 or more medications?
15. Macular degeneration that needs injections?

5 In the last 2 years, have you been diagnosed with or treated for…

Answer about the past 24 months.

16. Internal cancer, melanoma, leukemia, Hodgkin’s disease, lymphoma, or myeloma?
17. Crohn’s disease, ulcerative colitis, rheumatoid arthritis, psoriatic arthritis, lupus, or scleroderma?
18. A heart or circulation problem — such as stroke, mini-stroke (TIA), heart attack, bypass, angioplasty, stent, angina, pacemaker, blood clot (DVT), cardiomyopathy, congestive heart failure, aneurysm, atrial fibrillation or other irregular heartbeat, or peripheral vascular disease?
19. Chronic liver disease, such as cirrhosis or hepatitis B or C?
20. Chronic kidney disease, kidney failure, or dialysis?
21. COPD, emphysema, other chronic lung disease (mild asthma doesn’t count), or use of oxygen?
22. Epilepsy or a seizure disorder?
23. A blood disorder? (Mild anemia doesn’t count.)
24. Arthritis that is disabling or limits your mobility, osteoporosis with a related fracture (broken bone), severe spinal stenosis, degenerative bone disease, or an amputation caused by disease?
25. In the past 24 months, have you been treated for or diagnosed with bipolar disorder or schizophrenia?
26. In the past 24 months, have you been treated for or diagnosed with a mental/nervous condition or major depression?
27. Alcohol, drug, or opioid abuse or addiction?
28. Ongoing opioid or narcotic medication prescribed through a pain management doctor or clinic?

6 In the last 12 months

Answer about the past 12 months.

29. In the last 12 months, have you had injections or infusions — or has a doctor advised you to get them — for any condition? For example: eye conditions, migraines, osteoporosis (such as Prolia or Reclast), back or spine pain, overactive bladder (such as Botox), or joint pain or arthritis (such as cortisone or gel shots).

7 Height, weight, and tobacco

Have you used tobacco or nicotine in any form (cigarettes, cigars, pipe, chewing tobacco, e-cigarettes or vaping, nicotine gum or patches) in the last 12 months?

8 Prescriptions

The insurance company reviews prescription history, so a complete list helps us give you an accurate answer.

9 Confirm and send