Form Sb.eelng.10.mo - Employee Enrollment Form - 2010 Page 3
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4F. Medical History
Employee Name ____________________________ SSN _____________________ Group Name __________________________________
Has anyone on this application consulted with or been examined or treated by any health care professional during the last 5 years for any
illness, injury, or health condition in any of the categories listed below? If yes, please check the box that most appropriately describes the
problem and explain fully below. I understand the purpose of the disclosure and use of my information is to allow The Company and Affiliates
to make decisions regarding eligibility, enrollment, underwriting and premium risk rating. Please note that, if you leave out or misrepresent
information, we may terminate or not renew your coverage, or we may change your premium retroactive to the date your policy became
effective. UnitedHealthcare is only seeking to collect information about the current health status of those persons listed on the application. In
answering these questions, you should not include any genetic information. Please do not include any family medical history information or
any information related to genetic services or genetic diseases for which you believe you or your dependents may be at risk.
1 Cancer
Breast
Colon
Leukemia
Lymphoma
Liver
Lung
Melanoma
Other ___________________
Yes
No
Testicular
Brain
Ovarian
Cervical
Prostate
Stage _____
2 Heart/Circulatory
Aneurysm
Bypass
Angioplasty/Stent
Congestive Heart Failure
Elevated Cholesterol/Triglycerides
Yes
No
Heart Disease
High Blood Pressure
Stroke
Angina
Hemophilia
Blood Clots
Pacemaker
Blood Disorder
Sickle Cell Anemia
MI
Other ______________________________________________
3 Reproductive
Current Pregnancy (due date___________ )
Multiples (#___ )
Pregnancy Complications
Fibroids
Yes
No
Menstrual Disorders
Breast Disorders
Endometriosis
Infertility
Other _______________________
4 Intestinal/Endocrine
Chronic Pancreatitis
Colon Disorder
Crohn’s
Ulcerative Colitis
Diabetes
Cirrhosis
IBS
Yes
No
Hepatitis B/C
Reflux
Liver Disorder
Ulcer
Growth Hormones
Other_______________________
5 Brain/Nervous
Alzheimer’s Disease
Cerebral Palsy
Migraines
Multiple Sclerosis
Paralysis
Seizures/Epilepsy
Yes
No
Parkinson’s Disease
Tumor
Head Injury
Cyst
Other ____________________________________
6 Immune
Scleroderma
ALS
Rheumatoid Arthritis
Psoriasis
AIDS
HIV+
Lupus
Immuno Deficiency
Yes
No
Other_________________________ Please note: For AIDS and HIV, you are only required to check yes if you or
any person listed in Section B "Family Information" on the front of this form, has been diagnosed with AIDS or HIV.
7 Lung/Respiratory
Allergies
Asthma
Cystic Fibrosis
COPD/Emphysema
Sarcoidosis
Lung Disorders
Yes
No
Tuberculosis
Sleep Apnea
Other __________________________________________________________
8 Eyes/Ears/Nose/Throat
Acoustic Neuroma
Cataracts
Cleft Lip/Palate
Yes
No
Deviated Septum
Glaucoma
Retinopathy
Other____________________________________________
9 Urinary/Kidney
Chronic Kidney Stones
Kidney Disorders
Bladder Disorders
Polycystic Kidney Disease
Yes
No
Prostate Disorder
Renal Failure
Dialysis
Other ___________________________________________
10 Bones/Muscles
Osteoarthritis
Bulging/Herniated Disc
Joint injury
Fibromyalgia/CFS
Shoulder Disorder
Yes
No
Knee Disorder
Spina Bifida
Back Disorder
Neck Disorder
Other ___________________________
11 Behavioral Health
Anxiety/Depression
ADHD
Bipolar/Manic Depression
Schizophrenia
Autism
Eating Disorder
Yes
No
Suicide Attempt
Inpat ETOH/Drug
Inpat MH Hosp
Other ____________________________________
12 Transplant
Bone Marrow
Organ
Stem Cell
Discussed Possible Future Transplant
Yes
No
Transplant Complications Year _____
Other __________________________________________________
13 Rare Diseases
Gaucher disease
Fabry disease
Enzyme Deficiency
Metabolic disorder
Phenylketonuria (PKU)
Yes
No
Marfan Syndrome
Other __________________________________________________
14 Medication
Current Medications Please List Meds__________________________________________________________
Yes
No
Medications Taken Within The Past Year Please List Meds __________________________________________
15 Other
Abnormal Test Or Physical Results
Condition Not Mentioned Above
Yes
No
Treatment Or Surgery Discussed Or Advised
Pending Test Results
Inpat Hosp/Surg in Past Yr.
Pending w/c claim
Tests Advised or Recommended
Refer to Specialist
Disability
Please give details below (If additional space is required, please attach a separate sheet and be sure to date and sign that sheet)
Question #
Person
Condition/Diagnosis
Treatment
Current Meds
Physician’s Name Dates Treated Prognosis
SB.EELNG.10.MO 6/10
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