Application For Enrollment Form (Page 2 of 4) in pdf

(PART II)

APPLICANT INFORMATION:

Please list your name and the name(s) of all dependents for whom you wish to obtain

coverage. Attach additional sheets if necessary.

SEX

APPLICANT NAME(S)

AGE

HEIGHT

WEIGHT

If applicant or family member received care under another name(s), please list other name(s).

HEALTH QUESTIONNAIRE:

All questions must be checked () Yes or No. If answer is “Yes”, circle the appropriate

condition(s) and give details in the space provided below.

Have you or any applying family member ever received any professional medical advice or treatment or had any

YES

symptoms pertaining to any of the following conditions?

Dizziness, seizure, epilepsy, migraine, paralysis, stroke, muscular dystrophy, multiple sclerosis, cerebral palsy or other brain or

nervous system disease or disorder?

Hypertension or high blood pressure, palpitation, chest pain, high cholesterol level, hyperlipidemia, ischemic heart disease,

coronary artery disease (CAD), heart attack, heart murmur, heart valve problem, rheumatic fever or other heart or cardiovascular

disease or disorder?

Anemia, varicose veins, peripheral vascular disease, phlebitis, bleeding problem or other circulatory system disease or disorder?

Allergies, asthma, reactive airway disease, sinusitis, emphysema, tuberculosis, chronic obstructive pulmonary disease (COPD)

or other respiratory disease or disorder?

Mouth, tongue, esophageal or stomach problem, ulcer, intestinal bleeding, gallbladder stone, jaundice, cirrhosis, hepatitis,

pancreatitis, polyp, hernia, hemorrhoids or other digestive disease or disorder?

Kidney stone, urethral stricture, bladder problem, infection or other urinary tract disease or disorder?

Male Reproductive System: such as prostate problem, infertility, impotence, gynecomastia, syphilis, gonorrhea or other venereal

disease or others?

Female Reproductive System: such as breast mass, implants, endometriosis, fibroids, myoma, vaginal bleeding, vaginitis,

abnormal Pap test, infertility, genital warts, Chlamydia infection or other menstrual or gynecological disease or disorder?

Arthritis, sciatica, herniated or bulging disc, scoliosis, carpal tunnel syndrome, fractures or other muscle or bone disease or

disorder including back or joints?

Diabetes, goiter, gout, adrenal disorder, growth hormone deficiencies, lupus, acquired immune deficiency syndrome (AIDS), or

other metabolic, endocrine, nutritional and immune system disease or disorder?

Skin cancer, dermatitis, eczema, mole, acne, psoriasis, warts, skin tags, birthmarks, burns or other skin disease or disorder?

Cataract, glaucoma, retinal detachment, pterygium, crossed eyes, polyp, deviated nasal septum, sleep apnea, tonsils and

adenoids problems or other eyes, ears, nose or throat disease or disorder?

Cancer, cyst, or tumor, Leukemia, Hodgkin’s disease, Lymphoma or other blood or lymph disease or disorder?

Down syndrome, cleft lip or palate, clubfoot, developmental delay, mental retardation or other birth defect or congenital disease

or disorder?

Alcoholism, Drug dependency or Substance abuse?

SW-APP PART II 02/12

Application For Enrollment Form Page 2