Lindsay Hyde
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Marital Status
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Medicare Coverage Start Date
Are you currently enrolled in any of the following?
*
Original Medicare (Part A & B)
Medicare Advantage Plan (Part C)
Medicare Prescription Drug Plan (Part D)
Medicaid
Employer or Union Health Coverage
None of these
Have you been diagnosed with or treated for any of the following conditions in the last 5 years?
*
Heart Disease or Chest Pain
Stroke or TIA (Mini-Stroke)
Cancer or Tumors
Diabetes
COPD, Asthma, or Chronic Lung Disease
Kidney or Liver Disease
Mental Health Disorders (e.g., Depression, Anxiety, Bipolar Disorder)
Alzheimer’s, Dementia, or Memory Loss
None of these
Do you currently take prescription medications?
Yes
No
Please list the names of the medications and the conditions they are for:
Have you been hospitalized or had surgery in the last 2 years?
Yes
No
Please provide details (reason, date):
Have you used tobacco products in the last 12 months?
Yes
No
Do you require any assistance with daily living activities (e.g., bathing, dressing, eating)?
Yes
No
Are you under 65 and receiving Medicare due to disability?
Yes
No
Do you have any of these chronic conditions?
*
ESRD (End-Stage Renal Disease)
ALS (Lou Gehrig’s Disease)
Diabetes
Cardiovascular Disease
Chronic Lung Conditio
None of these
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