Careers | Senior Solutions Life | Insurance Agent Training in Naperville, IL
(800) 745 - 0375 info@seniorsolutionslife.com

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Fill out Senior Solutions’ Health Survey Questionnaire below and get started!

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Health Survey Questionnaire

Are you currently hospitalized or reside in a nursing home?

Do you require assistance with activities of daily living such as eating, bathing, dressing, or toiletries?

Do you use a walker, wheelchair, or electric scooter?

Have you ever had a heart attack, stroke, or cancer? Provide a dropdown to provide any details and dates of condition.

Do you have any lung / respiratory issues that require the use of inhalers or oxygen?

Have you ever been treated for any kidney or liver diseases including hepatitis or cirrhosis?

Have you ever been treated for Alzheimer's, dementia, or memory loss?

Have you ever been treated for diabetes?

Do you have any planned surgeries that have not been performed yet?

Have you ever been convicted of a felony?

Have you used any nicotine or tobacco products in the last 12 months?