Daboussi Insurance Services

Individual and Family
Health Assessment

All the information you provide will be held in confidence and will be used only to assist us in ensuring that you get the right health care plan for yourself or your family.

Gender: *
Male   Female

Date of Birth: *
  

Height: *

  
Weight: *
   Tobacco?
Yes   No

Would you like to include a spouse?
Yes   No

Spouse's Name:

  

Gender
Male   Female

Date of Birth
  

Height

Weight:
   Tobacco?
Yes   No
How many children would you like to include?*
(You will be able to provide information for each child on the next page)

Is anyone included in this request pregnant?*
Yes   No

Has anyone been treated by a doctor for a major health condition in the past year?*
Yes   No

Has anyone been hospitalized in the past 5 years (excluding pregnancy)?*
Yes   No

Has anyone been denied coverage in the past year?*
Yes   No

Are you self employed?*
Yes   No 		 

Do you currently have health insurance?*
Yes   No

Who is your current health insurance carrier? *

Does anyone take prescription medications? *
Yes   No

Please list the prescription medications:

Does anyone have any major health conditions? *
Yes   No

Please select any health conditions that apply:

AIDS / HIV   Emphysema   Kidney Disease
Alcohol / Drug Abuse   Epilepsy   Mental Illness
Alzheimer's / Dementia   Heart Attack   Multiple Sclerosis
Asthma   Heart Disease   Pulmonary Disease
Cancer   Hepatitis / Liver   Stroke
Clinical Depression   High Blood Pressure   Ulcers
Diabetes   High Cholesterol   Vascular Disease
   

Other / Not Listed
If other, please list conditions:

First Name: *

  

Last Name: *

  

Street Address: *

City: *

  

State: *

  

Zip Code: *

Day Phone: *

  

Evening Phone:

    

Email Address: *

  

Confirm Email: *

    
Comments and questions: