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
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  
15) Hepatitis
inactive and type a or b
active or type c, d, e, f
16) Systemic Lupus
17) Lyme disease
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
with smoking or Claudication
23) Schizophrenia
24) Stroke
with diabetes
25) TIA
  with diabetes
26) Walker use
27) Wheelchair use
28) Quad cane


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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