Health Statement 2 - 24 Enrolled Employees Form

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HEALTH STATEMENT 2 - 24 Enrolled Employees
®
Registered Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.
Name:
Employee Social Security #: __ __ __ - __ __ - __ __ __ __
Name of Employer:
Employee: Height: ______ ft. _____ in. /
Weight: ______ lbs.
Spouse: Height: ______ ft. _____ in. /
Weight ______ lbs.
(if coverage is to include spouse)
The following questions apply to ALL persons, including dependents, applying for coverage. Please provide details of any “yes” answers in the space provided or in an attached and
signed document. In the past ten (10) years, have you or any persons listed on the application been diagnosed, treated or advised to seek treatment or testing, or had symptoms related
to any of the following:
1. Blood Disorders/
Anemia
Aneurysm
Angina/Chest Pain
Angioplasty/By-Pass
Blood Clot
Carotid Artery Disease
Circulatory System
Congestive Heart Disease
Coronary Artery Disease
Elevated Cholesterol/Triglycerides
Heart Attack
Heart Murmur
Yes
No
Hemophilia
Irregular Heartbeat
Phlebitis
Polycythemia Vera
Sickle Cell
Stroke
Varicose Veins
High Blood Pressure
(Last three readings/date (Ex. 120 / 80 03 / 13 / 04))
1. __________ _____/_____/_____
2. __________ _____/_____/_____
3. __________ _____/_____/_____
Other (specify)__________________________________________________________________________________________
Patient’s Name__________________________________________________________________________________________
Diagnosis/Treatment/Medication_____________________________________________________________________________
Current Status ______________________________________________________ Date Diagnosed ______________________
Date of Last Doctor Visit_________________ Doctor’s Name/Phone_______________________________________________
2. Bones/Injuries/
Rheumatoid Arthritis
Arthritis (Other)
Broken/Fractured Bones
Bulging/Herniated Disc
Fibromyalgia
Muscles and Tissues
Lupus
Necrosis
Back/Neck Disorder (specify)___________________
Other (specify)_________________
Patient’s Name__________________________________________________________________________________________
Yes
No
Diagnosis/Treatment/Medication_____________________________________________________________________________
Current Status ______________________________________________________ Date Diagnosed ______________________
Date of Last Doctor Visit_________________ Doctor’s Name/Phone_______________________________________________
3. Congenital Anomalies/
Cleft Lip
Cleft Palate
Polycystic Kidney
Spina Bifida
Other (specify)_______________________
Birth Defects
Patient’s Name__________________________________________________________________________________________
Diagnosis/Treatment/Medication_____________________________________________________________________________
Yes
No
Current Status ______________________________________________________ Date Diagnosed ______________________
Date of Last Doctor Visit_________________ Doctor’s Name/Phone_______________________________________________
4. Digestive System
Cirrhosis of Liver
Hepatitis (specify type)____________
Other Liver Disorder (specify)__________________
Yes
No
Crohn’s/Ulcerative Colitis
Colon Disorders (specify)________________________________
Gallbladder
Hernia (specify type)________
Pancreatitis
Reflux
Ulcer (specify)________
Other (specify)__________
Patient’s Name__________________________________________________________________________________________
Diagnosis/Treatment/Medication_____________________________________________________________________________
Current Status ______________________________________________________ Date Diagnosed ______________________
Date of Last Doctor Visit_________________ Doctor’s Name/Phone_______________________________________________
5. Endocrine System
Diabetes:
Oral Medication________________________________ Dosage______________________________
Daily Insulin Dosage
AM Units_______
PM Units_______
Yes
No
Last three Blood Sugar Readings (Ex. 140 03 / 13 / 04)
1. __________ _____/_____/_____
2. __________ _____/_____/_____
3. __________ _____/_____/_____
Cystic Fibrosis
Goiter
Gout
Pituitary Dwarfism
Thyroid
Other (specify)_______________
Patient’s Name__________________________________________________________________________________________
Diagnosis/Treatment/Medication_____________________________________________________________________________
Current Status ______________________________________________________ Date Diagnosed ______________________
Date of Last Doctor Visit_________________ Doctor’s Name/Phone_______________________________________________
6. Infectious/Parasitic
HIV/AIDS
Sarcoidosis
Tuberculosis
Other (specify)______________________________________
Conditions
Patient’s Name__________________________________________________________________________________________
Diagnosis/Treatment/Medication_____________________________________________________________________________
Yes
No
Current Status ______________________________________________________ Date Diagnosed ______________________
Date of Last Doctor Visit_________________ Doctor’s Name/Phone_______________________________________________
Alcohol Abuse
Anxiety/Depression
Bipolar
Drug Abuse
Anorexia
Bulimia
7. Mental Health
Other (specify) ________________________________________________________________________________________
Conditions/Substance
Patient’s Name___________________________________________________________________________________________
Abuse
Diagnosis/Treatment/Medication_____________________________________________________________________________
Yes
No
Current Status ______________________________________________________ Date Diagnosed ______________________
Date of Last Doctor Visit_________________ Doctor’s Name/Phone_______________________________________________
12068M (5/06)
(continued on back)

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