210 Health Questions from the Kaiser Application
We finally ditched our amazingly expensive COBRA health care plan in favor of individual health care policies. Unlike the plans I've had from employers in the past, this individual plan required each of us to answer questions about our healthcare history. Presumably this is so they can disqualify people who already live with expensive health conditions.
I was pretty impressed by the application. The PDF was 24 pages, letter-sized, with the majority of the questions related to health. It starts like this:
Basic Questions
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Name |
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Address |
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SSN |
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Gender |
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Date of Birth |
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Marital Status |
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Height |
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Weight |
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Language |
Then they ask you the medical history questions.
Medical Questions
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1. Hospitalizations - Within the last 12 months, were you hospitalized (excluding labor and delivery. or treated at an Emergency Department, hospital, outpatient surgery center, or skilled nursing facility? |
YN? |
2. Office Visits - Within the last 12 months, have you sought advice or treatment from a medical professional's office? |
YN? |
2a. Physical exam |
YN? |
2b. Minor illness or injury now resolved and without a recommendation of further treatment; for example, cold, allergic reaction, flu, sore throat, cut requiring stitches |
YN? |
2c. Chiropractic visits |
YN? |
2d. Prenatal care |
YN? |
2e. Psychological counseling |
YN? |
2f. Medication management |
YN? |
2g. A reason not listed above |
YN? |
3. Pending Treatment - Within the last 3 years, have you been advised by a medical professional to have, but have not yet had, surgery, treatment, examination, evaluation, or test for any medical condition? |
YN? |
4. Substance Abuse Treatment - Within the last 3 years, have you been instructed to attend, attended, or participated in a program that deals with your alcohol or substance abuse? |
YN? |
5. Skin/Dermatological - Within the last 3 years, have you been treated for, or has a medical professional advised you that you have, any skin/dermatological disorders? |
YN? |
5a. Acne |
YN? |
5b. Psoriasis |
YN? |
5c. Burns |
YN? |
5d. Keloids requiring plastic surgery |
YN? |
5e. Cosmetic or reconstructive surgeries, revisions |
YN? |
5f. A skin or dermatological condition not listed above |
YN? |
6. Eyes/Ear/Nose/Throat - Within the last 3 years, have you been treated for, or has a medical professional advised you that you have, any disorders of the eyes, ears, nose, or throat? |
YN? |
6a. Glaucoma |
YN? |
6b. Cataracts, cataract surgery for one or both eyes |
YN? |
6c. Crossed eyes |
YN? |
6d. Detached retina |
YN? |
6e. Macular degeneration |
YN? |
6f. Deviated septum |
YN? |
6g. Sleep apnea, chronic snoring, or unresolved insomnia |
YN? |
6h. Nasal and/or throat polyps |
YN? |
6i. A condition of the eyes, ears, nose, or throat not listed above |
YN? |
7. Tobacco History - Have you ever used tobacco, including snuff and chewing or other smokeless tobacco? |
YN? |
8. Illegal Drugs - Within the last 5 years, have you taken or used illegal drugs or prescription drugs not prescribed by a medical professional? |
YN? |
9. Nervous System - Within the last 5 years, have you been treated for, or has a medical professional advised you that you have, any brain neurological, or nervous disorder? |
YN? |
9a. Multiple sclerosis |
YN? |
9b. Autism |
YN? |
9c. Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) |
YN? |
9d. Seizures treated with more than 2 medications for control |
YN? |
9e. Seizures under control with 2 or fewer medications |
YN? |
9f. Most recent seizure within the last 12 months |
YN? |
9g. Alzheimer's disease |
YN? |
9h. A brain, neurological, or nervous disorder not listed above |
YN? |
10. Cardiovascular System - Within the last 5 years, have you been treated for, or has a medical professional advised youthat you have, any heart or cardiovascular disorders? |
YN? |
10a. Aneurysm |
YN? |
10b. Heart murmur or mitral valve prolapse, with recommendation for ongoing treatment |
YN? |
10c. Chest pain |
YN? |
10d. Heart attack or angina |
YN? |
10e. Congestive heart failure |
YN? |
10f. Angioplasty or coronary artery bypass |
YN? |
10g. Pacemaker |
YN? |
10h. Tachycardia or other heart arrhythmia |
YN? |
10i. Other heart disease or valve disease |
YN? |
10j. Current medications to control heart disease or cardiovascular symptoms |
YN? |
10k. A heart or cardiovascular condition not listed above |
YN? |
11. Respiratory System - Within the last 5 years, have you been treated for, or has a medical professional advised you that you have, any respiratory disorders? |
YN? |
11a. Chronic asthma treated with medications for control |
YN? |
11b. Asthma treated with prednisone therapy |
YN? |
11c. Asthma treated only with occasional use of inhalers |
YN? |
11d. Asthma history of 3 or more Emergency Department visits or hospital admissions within the last 12 months |
YN? |
11e. Emphysema |
YN? |
11f. Chronic bronchitis |
YN? |
11g. Chronic obstructive pulmonary disease |
YN? |
11h. Cystic fibrosis |
YN? |
11i. Pulmonary tuberculosis, active or arrested |
YN? |
11j. A lung or respiratory disorder not listed above |
YN? |
12. Musculo-skeletal System - Within the last 5 years, have you been treated for, or has a medical professional advised you that you have, any muscle or bone disorders? |
YN? |
12a. Back or neck pain or injury currently under treatment or controlled with medication |
YN? |
12b. Back or neck pain or injury within the last 12 months fully resolved and no longer under treatment |
YN? |
12c. Back or neck pain or injury for which further treatment or surgery has been recommended |
YN? |
12d. Inguinal hernia that has been repaired |
YN? |
12e. Inguinal hernia not repaired |
YN? |
12f. Umbilical hernia that has been repaired |
YN? |
12g. Umbilical hernia not repaired |
YN? |
12h. Lupus/SLE |
YN? |
12i. Chronic disabling arthritis |
YN? |
12j. Arthritis requiring daily prescription medication |
YN? |
12k. Osteomyelitis |
YN? |
12l. Joint replacement surgery |
YN? |
12m. Orthopedic or arthritic conditions that interfere with daily living (Examples of daily living include bathing, dressing, grooming, or walking). |
YN? |
12n. A musculoskeletal condition not listed above |
YN? |
13. Metabolic/Endocrine System - Within the last 5 years, have you been treated for, or has a medical professional advised you that you have, any metabolic or endocrine (hormone) disorders? |
YN? |
13a. AIDS |
YN? |
13b. Diabetes controlled with oral medication |
YN? |
13c. Diabetes controlled with insulin |
YN? |
13d. Diabetes controlled exclusively with diet and exercise |
YN? |
13e. Gestational diabetes |
YN? |
13f. High cholesterol |
YN? |
13g. Rheumatoid arthritis |
YN? |
13h. Muscular dystrophy |
YN? |
13i. Other immunological condition |
YN? |
13j. A metabolic or endocrine disorder not listed above |
YN? |
14. Congenital/Developmental - Within the last 5 years, have you been treated for, or has a medical professional advised you that you have, any congenital defects or developmental disorders? |
YN? |
14a. Down's syndrome |
YN? |
14b. Cerebral palsy |
YN? |
14c. Cleft palate or lip |
YN? |
14d. Club foot |
YN? |
14e. Congenital heart defect (specify type) |
YN? |
14f. Developmental delay |
YN? |
14g. Prematurity (for children up to 2 years old. |
YN? |
14h. A neurological or physical abnormality not listed above (specify) |
YN? |
15. For Males only: Within the last 5 years, have you been treated for, or has a medical professional advised you that you have, any of the following: |
YN? |
15a. Prostate condition requiring treatment, medication, or surgery |
YN? |
15b. Genital herpes with a history of daily treatment or more than 3 outbreaks in the last 12 months |
YN? |
15c. Genital warts |
YN? |
15d. Syphilis |
YN? |
15e. Gonorrhea |
YN? |
15f. Other sexually transmitted disease |
YN? |
15g. Impotence or erectile dysfunction |
YN? |
15h. Infertility |
YN? |
15i. Gender identity (role) disorder |
YN? |
15j. A male reproductive or genital disorder not listed above |
YN? |
16. (Womans questions) |
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17. Digestive System - Within the last 5 years, have you been treated for, or has a medical professional advised you that you have, any digestive system disorders? |
YN? |
17a. Ulcerative colitis or Crohn's disease |
YN? |
17b. Gastrointestinal bleeding |
YN? |
17c. Gastrointestinal polyps |
YN? |
17d. Unrepaired cystocele or rectocele |
YN? |
17e. Gallstones and gallbladder has not been removed |
YN? |
17f. Hepatitis A, B, C, or other, currently under treatment |
YN? |
17g. Hepatitis A, B, C, or other, chronic and ongoing (including carrier status. |
YN? |
17h. Cirrhosis |
YN? |
17i. Hepatitis A, fully recovered with no symptoms and normal liver function tests |
YN? |
17j. Other liver condition |
YN? |
17k. A digestive system disorder not listed above |
YN? |
18. Urinary Tract - Within the last 5 years, have you been treated for, or has a medical professional advised you that you have, any urinary tract disorders? |
YN? |
18a. Chronic kidney failure |
YN? |
18b. Nephrotic syndrome |
YN? |
18c. Polycystic kidneys |
YN? |
18d. Kidney failure |
YN? |
18e. Chronic kidney infections (more than 2 per year. |
YN? |
18f. Kidney infection, resolved with no further treatment required |
YN? |
18g. Kidney removed with remaining kidney functioning without any medical problems and normal kidney function tests |
YN? |
18h. Kidney removed with a recommendation for further treatment |
YN? |
18i. Kidney stones, currently |
YN? |
18j. Kidney stones within the last 24 months |
YN? |
18k. Interstitial cystitis |
YN? |
18l. A kidney or urinary tract disorder not listed above |
YN? |
19. Lab Results - Within the last 5 years, has a medical professional advised you that you have any abnormal lab results? |
YN? |
20. Circulatory System - Within the last 10 years, have you been treated for, or has a medical professional advised you that you have, any blood or circulatory system disorders? |
YN? |
20a. Stroke |
YN? |
20b. Transient ischemic attacks (TIA) |
YN? |
20c. Hemophilia |
YN? |
20d. Thalassemia major |
YN? |
20e. Von Willebrand's disease |
YN? |
20f. Other blood disorder |
YN? |
20g. Blood pressure over 150/90 |
YN? |
20h. Currently taking 3 or more medications for hypertension |
YN? |
20i. Hypertension under control with medication |
YN? |
20j. A blood or circulatory system disorder not listed above |
YN? |
21. Cancer - Within the last 10 years, have you been treated for, or has a medical professional advised you that you have, any cancer? |
YN? |
21a. Any cancer with lymph node involvement or metastasis (spread to other tissue) |
YN? |
21b. Cancer of the brain, breast, blood, pancreas, prostate, urinary bladder, esophagus; or myeloma, Kaposi's sarcoma, or non-Hodgkin's lymphoma |
YN? |
21c. Cancer of the cervix, uterus, thyroid, larynx, or oral cavity, with no further treatment recommended |
YN? |
21d. Cancer of the colon, kidney, liver, lung, ovary, or stomach |
YN? |
21e. Skin cancer that has not been removed and requires further treatment |
YN? |
21f. Skin cancer other than melanoma that has been completely removed and no further treatment recommended |
YN? |
21g. Melanoma |
YN? |
21h. A cancer not listed above |
YN? |
22. Prosthetics/Implants/Transplants - Within the last 10 years, have you been treated for, or has a medical professional advised you that you have, any condition for which prosthetics, implants, or transplants (including organ transplants. have been recommended? |
YN? |
23. Mental Health - Within the last 10 years, have you been treated for, or has a medical professional advised you that you have, any psychological or mental health disorders? |
YN? |
23a. Mild depression/anxiety |
YN? |
23b. Major depression or neurosis |
YN? |
23c. Situational stress, anxiety, or depression no longer requiring treatment or medication |
YN? |
23d. Eating disorder (anorexia nervosa or bulimia) |
YN? |
23e. Suicide attempt |
YN? |
23f. Psychosis, senile dementia, multiple personalities, bipolar disorder, depressive psychosis, schizophrenia |
YN? |
23g. Hospitalization for a mental health condition |
YN? |
23h. A psychological or mental health condition not listed above |
YN? |
24. Prescriptions - Are you taking any prescription medications? |
YN? |
25. Alcohol - Do you drink alcoholic beverages? |
YN? |
26. Pregnancy - Are you currently pregnant or an expectant father? Or, do you expect to be providing medical insurance coverage for a newborn or new adoptee within the next 9 months? |
YN? |
27. Surrogacy - Do you plan to be a surrogate parent (mother or father) within the next year or to engage someone to provide that service within the next year? |
YN? |
28. Some female questions |
YN? |
29. Other: Within the last 5 years, have you been treated for, or advised by a medical professional that you have, a medical or health-related condition which you haven't indicated on this Medical Questionnaire? |
YN? |
Almost done!
Medical Details
Except, if you answered Yes or "?" to any of those 210 health questions, you've got to clarify what happened in each instance, as shown in the Medical Detail section below. These questions need to be addressed if you, for example, answered "?" to Question 20e: Von Willebrand's disease :
Medical Detail
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20e. Circulatory System - Von Willebrand's disease *If you answered ? to this question, please check all boxes that apply |
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I don't understand the question. | |
I had the condition listed but can't remember when. | |
I don't understand the medical terms being used in question. | |
I don't remember the date that I consulted a physician or was admitted to a hospital. | |
I don't remember the information that I need to provide in order to answer the question correctly. | |
I don't know if I have or have had this condition. | |
*Please provide a complete explanation of why you answered "?". |
This is where you'll give details about when you visited the urologist to get Viagra, just so you could write an article about it.
These forms are simpler to fill out if you haven't had a lot of health problems, just one of the benefits of clean livin'.
After you fill out the paper application, you can mail it in, or fax it in. You'll have to include your first month's insurance premium, although they don't yet guarantee that they will enroll you for the plan. You are only applying.
It was our experience that upon receiving the application, a Kaiser representative will call and ask about each and every unaddressed question from the application. They don't seem too terribly anxious to determine if you are lying, though. I have a feeling that if you show up with stage 3 Cystic Fibrosis a week after applying, they'll use your fraudulent application to avoid having to administer care at the insured rates.
So, that's it. Two hundred ten health questions, plus details, and you are ready to go. You can do it.
The guys at H & R Block can't.
I already asked.
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