G. Health Questionnaire (continued)
2. Heart / vascular
Yes
No
Aneurysm (location
)
Blocked arteries (e.g., carotid, heart, abdomen, legs)
Heart attack
Heart valve disorder
Congestive heart failure
Cardiomyopathy
Irregular or abnormal heart rhythm
Stroke
Vasculitis (type
)
Bypass / angioplasty / stent (location
)
Pacemaker or cardiac defibrillator
Other (specify details below)
3. Blood / clotting disorder
Yes
No
Hemophilia (specify type below)
Anemia (specify type below; e.g., sickle cell, hemolytic, aplastic)
Blood clots
Other (specify details below)
4. Reproductive / Gynecological
Yes
No
Current pregnancy: specify if it’s a spouse, dependent child or other expectant parent even if not listed on the application (due date
, if multiples #
, any complications
)
Intending to adopt
Infertility
Other Gynecological conditions (specify details below)
5. Gastrointestinal / endocrine
Yes
No
Diabetes
Crohn’s / ulcerative colitis
Autoimmune hepatitis
Hepatitis B (specify below if acute or chronic)
Hepatitis C (if cured, when did treatment end?
)
Cirrhosis
Pancreatitis
Growth disorder
Adrenal, pituitary, thyroid gland disorder (specify type below)
Other disorders of the gallbladder, stomach, pancreas, liver, colon (specify type below)
6. Brain / neurological
Yes
No
Amyotrophic lateral sclerosis
Cerebral palsy
Neuropathy / polyneuropathy
Multiple sclerosis
Myasthenia gravis
Muscular dystrophy
Brain and / or spinal cord disorder or injury
Paralysis, quadriplegia, paraplegia
Other (specify details below)
7. Immune / dermatology
Yes
No
HIV or AIDS
Immunodeficiency disorder
Connective tissue disorder (specify type below; e.g., lupus, scleroderma)
Hereditary angioedema
Skin disorder (specify type below; e.g., psoriasis, eczema, ulcers, infections)
Other (specify details below)
8. Lung / respiratory
Yes
No
Cystic fibrosis
COPD, chronic bronchitis, emphysema
Pulmonary hypertension
Pulmonary fibrosis
Other (specify type below; e.g., asthma, sarcoidosis, etc.)
9. Urinary / kidney
Yes
No
Kidney disease / disorder (specify type below)
Kidney failure
Dialysis: date started
Dialysis possible within the next 18 months
Bladder disorder
Prostate disorder
Other (specify details below)
10. Musculoskeletal
Yes
No
Rheumatoid or psoriatic arthritis (specify type below)
Disorder of the back / neck / spine
Disorder of the joints (specify location; e.g., hips, knees, shoulders)
Chronic pain disorder
Osteomyelitis
Amputation
Other (specify details below)
11. Mental health / substance abuse
Yes
No
Alcohol and / or drug abuse (specify type below)
Eating disorder
Anxiety / depression
Bipolar disorder
Schizophrenia
Suicide attempt
Oppositional defiant / conduct disorder
Autism
ABA therapy
Other (specify details below)
12. Transplant
Yes
No
Organ or bone marrow / stem cell transplant already performed (date
)
Future transplant planned / scheduled (date
)
Transplant discussed / recommended / possible within the next 18 months
Transplant complications
Other (specify details below)
Continued on next page
GR-69452 (3-24)
3
SG AFA IMQ
A
7 Slappey & Sadd, LLC 2025 Benefits Guide |
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