Slappey and Sadd, LLC - 2025 Benefits Guide

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)

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SG AFA IMQ

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7 Slappey & Sadd, LLC 2025 Benefits Guide |

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