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| Additional Health Questionnaires | |||
| When filling out your Individual Health Statement for Connecticare health insurance, you will be required to fill out a questionnaire form if you answered "YES" to any of the questions numbers below. Please send forms with your application and down payment | |||
| Check your health statement to see if you answered yes to the Question numbers below. | |||
| Application Area | Question Numbers | Health Condition | Questionnaire Form Required. |
| Click for form. | |||
| Part 2 | 1 | Headaches/Migraines |
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| 1 | Seizures/Epilepsy | Seizure/Epilepsy Form | |
| 2 | Heart Murmur/Mitral Valve | Heart Murmur / Mitro Valve Prolapse Form | |
| 3 | High Blood Pressure | Hypertension Form | |
| 4 | Asthma / Allergies | Respiratory Form | |
| 5 | Gastorintestinal Problems | Gastrointestinal Problems | |
| 6, 16 | Abnormal Pap Smear | Gynecological Services | |
| 6 | Urinary / Prostate/ | Urinary/Prostate Disorder Form | |
| 6,16 | Reproductive system | Gynecological Services | |
| 7 | Musculosketal pain | Back/Neck Pain Form | |
| 7 | Musculoskeletal Form | ||
| 8 | Endocrine/Metabolic/Thyroid | Thyroid Form | |
| 10, 14, 17 | Tumor/Cyst/Skin Cancer | Tumor/Cyst/Skin Cancer Form | |
| 12 | Nervous/Mental/Emotional Behaviors |
Alcohol & Drug Form | |
| Mental Health Form | |||
| Miscellaneous | Forms | Motor Vehicle Accident | Motor Vehicle Accident Form |
| General Health Form | General Health Form | ||
| Domestic Partner Form | Domestic Partner Form | ||
| JA August 12, 2010 | Go to ConnectiCare Insurance | ||