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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