Slappey and Sadd, LLC - 2025 Benefits Guide

G. Health Questionnaire (continued)

13. Birth / inherited conditions

Yes

No

Premature birth (gestational age:

# weeks)

Congenital birth defect

Genetic / metabolic disorder

Any syndrome (specify details below)

Other (specify details below)

14. Eyes / ears / nose / throat

Yes

No

Acoustic neuroma

Cataracts

Cleft lip / palate

Deviated septum

Glaucoma

Retinopathy

Chronic ear infections

Chronic sinusitis

Other (specify details below)

15. Medications

Yes

No

Current medications:

Person

# of meds

Person

# of meds

(list medication name(s) and diagnosis below)

Medications taken within the past 12 months:

Person

# of meds

Person

# of meds

(list medication name(s) and diagnosis below)

16. Incapacitated

Yes

No

Reason:

Disabled

Handicapped

Congenital disorder

Other (specify details below)

17. Other

Yes

No (specify details below)

Hospitalizations in the past 5 years

Future surgeries or hospitalizations discussed / planned / recommended / scheduled or possible within the next 18 months

Other conditions not addressed elsewhere in the application

Provide details below for all “yes” answers indicated above. If additional space is needed, attach a separate sheet. All attachments must be signed and dated by the applicant.

Ques.

Enrollee name

Conditions /

Date

Treatment

Medication names

Dates

Is treatment ongoing?

diagnosis

diagnosed

(include surgery, hospitalized,

(include those taken orally,

treated

I f yes , provide details of any

No.

durable medical equipment /

injected, infused, topically,

current OR future treatment.

supplies, etc.)

nasally, inhaled, etc.)

GR-69452 (3-24)

4

SG AFA IMQ

A

8 | Slappey & Sadd, LLC 2025 Benefits Guide

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