Employee General Health Survey - 

Your company is considering making a revision in their health benefits.  In order to do so, some general health information is needed in order to more accurately estimate the correct rates from different insurers and select a plan that meets your needs.

The following online forms information is confidential and will not shared with your employer.   If you have any questions, please do not hesitate to call me.

Mark Gurda - Castle Group Health Inc.   Tel: 847-559-8100 x201  ;  Email:  Markg@healthinsure.com

About You
Your Employer Name:
Your First Name and Last Initial
Your E-mail address:
Residence Town : State: Zipcode:

Your Age:                Your Gender:   

Who Will be Covered by Medical Insurance:
Number of Children taking Coverage (if applicable)   

Health Plan Preferences
What type of health plan do you prefer:
Would you like your plan to include maternity benefits.
Please list specific Dr.'s that you would like to be in the network.  Spelling is important.  List the physicians town as well.  ( e.g. Dr. Jones- Chicago,  Dr. Smith- Evanston)

Brief Health History -

Questions apply to all Family Members that wil be on the Group plan.

Please answer all 5 questions

1. Within the last 5 years have your received treatment for or medication for or been diagnosed for CANCER, STROKE, DIABETES, Heart or Vascular disease,  muscular or skeletal disease such as arthritis or lupus, alcohol or drug use, liver, kidney, lung disease, intestinal disease, or AIDS.  

Yes No
2. Within the last 2 years, have you received any counseling or treatment for mental or emotional disorders? Yes No
3. Are you or your dependent Now Pregnant? Yes No
4. Have you been hospitalized or had surgery in the past 12 months or have hospitalization or surgery advised to be done that has not been completed? Yes No
5. Are you currently taking any medications?  if YES, please list below?   Please list medication name, dosage, frequency, and approximate month/year that the medication started.  Yes No

"Yes"  Answers details go here:

 

 


Copyright © 2005 [Castle Group Health Inc.]. All rights reserved.
Revised: 09/6/05 .