1. Are you confined, scheduled for admission, or in the last two (2) years have you been confined to a nursing facility or assisted living facility?

2. Do you receive home health care services; or in the last two (2) years, have you received home health care services for more than three (3) separate periods of care?

3. Do you have a terminal illness; are you in the hospital, pending hospital admission, or have you been hospitalized more than two (2) times in the last two (2) years?

4. Do you receive assistance bathing, transferring, toileting, eating, dressing, or are you bedridden; have you been advised by a medical professional to use the assistance of a wheelchair, walker, or motorized mobility aid?

5. Within the past six (6) months, have you been treated for or advised by a medical professional to have treatment for diabetes with hypertension that required three (3) or more hypertension medications to control or diabetes requiring more than 50 units of insulin daily to control?

6. Within the past two (2) years, have you been treated for (including surgery) or advised by a medical professional to have treatment or surgery for any of the following:

Heart attack, congestive heart failure, coronary bypass, angioplasty, atherosclerosis or arteriosclerosis, peripheral vascular disease, carotid artery disease, coronary artery disease (CAD), angina, cardiomyopathy, stent placement, heart valve surgery, atrial fibrillation, irregular heartbeat, cardiac pacemaker, transient ischemic attack (TIA) or stroke?

7. At any time, have you been treated for (including surgery) or advised by a medical professional to have treatment or surgery for any of the following:

Muscular dystrophy, multiple sclerosis, or amyotrophic lateral sclerosis (Lou Gehrig’s disease)?

Paget’s disease, rheumatoid arthritis, disabling arthritis, osteoporosis with fractures, or paralysis?

Chronic kidney disease, Addison’s disease, renal insufficiency, renal failure, any kidney disease requiring dialysis, cirrhosis of the liver or any condition requiring an organ transplant?

Bipolar disorder, schizophrenia, a paranoid disorder, severe depression, or treatment for depression with medication for two (2) or more years?

Organic brain disorder?

Unrepaired aneurysm, hemophilia, or any other blood disorder?

Any heart disease requiring a permanent, implantable cardiac defibrillator?

Chronic obstructive pulmonary disease (COPD), chronic obstructive lung disease (COLD), emphysema, chronic bronchitis or other chronic lung or respiratory disorder not listed that requires the permanent use of oxygen?

Diabetes with neuropathy, diabetes with retinopathy, or diabetes with vascular disease?

Cerebral palsy, myasthenia gravis, systemic lupus, Parkinson’s disease?

Hepatitis other than hepatitis A or other liver disease?

Dementia, senility or Alzheimer’s disease?

PSA levels greater than 6.0

8. Within the past two (2) years, have you been treated for (including surgery) or advised by a medical professional to have treatment or surgery for any of the following:

Any cancer, excluding skin cancer (except malignant melanoma)?

Anemia requiring repeated blood transfusions?

Alcohol or drug abuse (including counseling)?

Pancreatitis?

Seizure?

9. At any time, have you been treated for or advised by a medical professional to have treatment for an amputation caused by disease or for an organ transplant (other than corneas)?

10. Have medical tests, treatment, therapy, or surgery been advised but not performed or is any surgery anticipated? (This excludes mammograms, pap tests, colonoscopies, or PSA tests which were advised for routine screening purposes only.)

11. Have you ever been diagnosed with or received medical advice or treatment from a physician or an appropriately-licensed clinical professional acting within his/her scope for Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human Immunodeficiency Virus (HIV) infection?