Health Condition

Please review the health conditions below and click on any condition which may apply
to your health history. If you make a mistake, click the re-set button at the bottom of the test to start over. Please be advised that your answers to the health test below ARE NOT forwarded to us and are not captured in our data base. This self test is purely provided for your information only.
 
                                         
1) Alcoholism
Rehabilitated, with 2 plus years abstinence  
   Rehabilitated, with 3 plus years abstinence  
  Not Abstinent  
  
2) Alzheimers
 
3) Arrhythmia/Atrial Fibrillation
  single episode
  multiple episodes or complications
 
4) Arthritis
Osteo
  Rheumatoid
With steroid use
 
5) Bypass surgery ( Over 6 months ago)
 
6) Cancer
 
Bladder in last 12 months
 
Over 12 months
 
Breast in last 12 months
 
Over 12 months
 
Colon in last 12 month
 
Over 12 months
 
Kidney in last 24 months
 
Over 24 months
 
Lung in last 24 months
 
Over 24 months
 
Skin in last 12 Months
 
Over 12 months
 
Ovarian last 24 months
 
Over 24 months
 
Prostate in last 24 months
 
Over 12 months
 
Thyroid in last 12 months
 
Over 12 months
 
Uterine in last 12 months
Over 12 months
 
7) Colitis
With steroids
 
8) Congestive Heart failure
single episode
multiple episodes
 
9) Diabetes
  Controlled with diet or oral meds  
Insulin use up to 100 units daily  
  Insulin use over 100 units daily  
with history of stroke or TIA  
  with peripheral vascular disease  
with neuropathy  
   with retinopathy  
 
 
10) Dialysis
 
11) Heart attack (over 6 months ago)
 
12) Kidney failure
 
13) Emphysema
with steroid use
with oxygen use
   
14) Incontinence
urinary, infrequent / stress  
  total or with undergarment use  
bowel  
 
15) Hepatitis
inactive and type a or b
active or type c, d, e, f
 
16) Systemic Lupus
 
17) Lyme disease
Cured
Under treatment
 
18) Memory problems
 
19) Multiple Sclerosis
 
20) Osteoporosis
with no fractures
with single fracture
with multiple fractures
 
21) Parkinsons disease
 
22) Peripheral vascular disease
mild
with smoking or Claudication
 
23) Schizophrenia
 
24) Stroke
single
multiple
with diabetes
 
25) TIA
  single
  multiple    
  with diabetes
  
26) Walker use
 
27) Wheelchair use
 
28) Quad cane
  

 

Visit New York Partnership for Long Term Care

National/New York Long-Term Care Brokers . 11 Executive Park Drive Clifton Park, NY 12065-5631
518 371-5522 / 800 695-8224 FAX 518 371-6131