Field Underwriting Questionnaire

Alzheimer’s Disease Cirrhosis Back Pain Cognitive Impairment Cystic Fibrosis Back Surgery Dementia Chronic Fatigue Syndrome Cerebral Palsy Memory Loss Multiple Sclerosis Myasthenia Gravis Confusion Post-polio Syndrome Syncope Recurrent Falls Parkinson’s Disease Peripheral Neuropathy Paralysis Lou Gehrig’s Disease / ALS Vertigo Chronic Pain Muscular Dystrophy Osteoporosis Tremor / Tremors Multiple Myeloma Vertebral Compression Fractures Huntington’s Chorea Other Related Fractures Ongoing Imbalance Hydrocephalus Fibromyalgia Ataxia Amputation Kidney Failure Back Disorder Any condition causing limited motion Chronic use of narcotic medications Glaucoma Macular Degeneration Retinitis Pigmentosa

Housekeeping Meal preparation Laundry Shopping Telephone use Managing finances Taking medications Transportation Bathing Dressing Eating Toileting Walking Controlling bowel or bladder Transferring in/out of bed or chair

Cane Walker Brace Wheelchair Motorized scooter Crutches Stair/chair lift Home intravenous medications Respirator Feeding tube Shunt Port-a-catheter Hospital bed Dialysis machine Personal oxygen system

Nursing home Assisted living facility Other custodial facility Home health care Adult day care Psychiatric Treatment Center Hospital facility