Form Gr-67834-2 - Aetna Texas Employee Enrollment/change Form Page 3
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H. Health Questionnaire for Groups Enrolling
Eligible Employees
(and employees of groups enrolling for Life coverage greater than the
Guaranteed Issue Level)
Health History for Employees and your Dependents.
The following information is confidential and will not be seen by or given to your employer.
ALL of the questions must be answered by you or your dependents or the enrollment form will be returned.
Incomplete enrollment forms may delay the effective date of your coverage.
Currently Taking
List all individuals enrolling for coverage.
Prescription
Sex
Age
Height
Weight
Smoker
Name
Medication(s)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Answer all the questions.
Within the last 5 years has anyone applying for coverage consulted, received treatment, by a doctor, psychiatrist, psychologist, or other practitioner
Yes
No
1.
or been diagnosed with any of the following conditions or disorders? (Check all that apply.)
a.
k.
Diabetes
Tumor/Cyst/Growth
t.
Birth Defects/Congenital Abnormalities
b.
l.
Infertility
Systemic or Discoid Lupus
u.
Arthritis/Bone/Joint/Muscle/Prosthetic Device
c.
m.
Endocrine/Metabolic
Lung or Respiratory
v.
Mental/Nervous/Emotional/Eating Disorder
d.
n.
Pancreas
Alcohol or Drug Use
w.
Stroke/Brain/Neurological
e.
o.
Liver/Hepatitis
Kidney/Bladder/Urinary
x.
Transplant:
Recommended
Pending
Complete
f.
p.
Immune System
Circulatory/Vascular
y.
Advised to have surgery or course of treatment not yet determined
g.
q.
Blood Disorder
Digestive/Stomach/Intestinal
z.
Cancer: Type:
` Stage
h.
r.
Epilepsy/Seizure
Central Nervous System
Surgery
Chemo
Radiation
i.
s.
Heart
Pituitary/Adrenal/Growth Disorder
aa.
Using:
Crutches
Walker
Wheelchair
j.
Paralysis/Paresis
bb.
Other
Yes
No
2.
Has anyone applying for coverage ever been diagnosed as having or been told by a medical doctor that they have AIDS, HIV or an ARC disorder?
Yes
No
3.
Is any female currently pregnant? If so, provide due date
Check applicable boxes:
C section planned
Multiple Births Expected (#
)
Complications:
Past or
Present
Has anyone applying for coverage incurred medical expenses in excess of $5,000 in the past 24 months?
4.
Yes
No
Has anyone applying for coverage been prescribed medications in the past 12 months?
5.
Yes
No
Does anyone applying for coverage have a known condition that requires on-going treatment?
6.
Yes
No
Do you or your spouse use tobacco products? If so, check the applicable boxes:
Yes
No
7.
Employee:
Cigarettes
Pipe
Cigars
Chewing Tobacco
Spouse:
Cigarettes
Pipe
Cigars
Chewing Tobacco
Provide details below to any boxes checked above. (If additional space is needed, attach a separate sheet and be sure to sign and date the sheet.)
Question
Date of
Date Treatment
Names of Prescription
Still Taking
Number
Name of Individual
Condition/Diagnosis
Onset
Ended
Medication(s)
Dosage
Medication
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If you are providing additional sheets, check here
and insert the sheets before sealing this Enrollment form.
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GR-67834-2 (3-11)
TX
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