Personal Information
Your Name
Spouse Name
Street Address
City
State
Zip Code
Phone
E-mail
Marital Status	Single Married
Affiliation	KCMS WSCPA Panorama City City of Auburn School District Employee No Affiliation

General Health Information
Date of Birth
Yourself:	Spouse:
How would you classify your current health?
Yourself: Excellent Good Fair Poor Select One	Spouse: Excellent Good Fair Poor Select One
How often do you exercise or leave the home for work or activities?
Yourself: 1-3 times/week 3-5 times/week 5 or more times/week Select One	Spouse: 1-3 times/week 3-5 times/week 5 or more times/week Select One
Have you used a tobacco product in the last 5 years?
Yourself: Yes No	Spouse: Yes No
Have you been hospitalized in the last 5 years?
Yourself: Yes No	Spouse: Yes No
Reason:	Reason:
Please list any medical conditions with which you have been medically diagnosed.
Yourself: Spouse:
Do you or your spouse currently own a Long Term Care Insurance Policy? If so, with which company?
Yourself: Yes No	Spouse: Yes No
Company:	Company:
Additional information that may help us assist you.

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