Preview Health Questionnaire

Health Questionnaire

To be completed by employee

Please provide complete information to assure timely administration of claims. Information provided will not cause medical

plan enrollment denial. (If you and your eligible dependents have chosen to waive health coverage, you are not required to complete

this questionnaire.)

Part I. Health plan information

Employee name: Gender: Height: Weight:

Social Security number: DOB: Employer name:

Part II. Health questionnaire

Please answer Yes or No to each of the following questions for yourself and each of your dependents. For each “Yes” answer, please

explain and provide complete details. Genetic Information Nondiscrimination Act of 2008 (GINA) Compliance Statement:

This is not a request for genetic information. In answering this Health Questionnaire, you should not include any genetic

information. That is, please do not include any family medical history or any information related to genetic testing, genetic

services, genetic counseling or genetic diseases for which you believe you may be at risk.

Have you or any of your dependents been diagnosed with, treated for, or had treatment recommended by a medical professional

within the last ﬁve (5) years for any of the following:

1) Heart or artery disease including heart attack, stroke, aneurysm, arteriosclerosis, chest pain,

rheumatic fever or heart murmur?

n Yes n No

2) Hypertension?

n Yes n No

3) Cancer, tumor or other malignancy?

n Yes n No

4) Diseases of the kidney, liver, gall bladder, pancreas or male/female organs or sexually transmitted disease

except HIV?

n Yes n No

5) Arthritis, back pain, rheumatic fever or musculoskeletal/joint problems?

n Yes n No

6) i. Immune deﬁciency disorders, infections or chronic infection problems not related to AIDS or AIDS-

Related Complex?

n Yes n No

ii. Have you or any applying family member been diagnosed as having or been treated for AIDS

(Acquired Immune Deﬁciency Syndrome) or ARC (AIDS-Related Complex)?

n Yes n No

7) Alcohol or substance abuse, mental/nervous disorders?

n Yes n No

8) Ulcer, colitis, difﬁculty swallowing, stomach problems, hernia or rectal problems?

n Yes n No

9) Diabetes, cystic ﬁbrosis, albumin or sugar in the urine or other endocrine problems?

n Yes n No

10) Asthma, emphysema, tuberculosis, pleurisy or other diseases of the lungs?

n Yes n No

11) Paralysis, epilepsy, MS or other neuromuscular disorder?

n Yes n No

12) Bleeding or blood disorders except HIV?

n Yes n No

(continued)

CA89632 (2/12)

Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, Inc. Health Net is a registered

Check one

n Initial enrollee n Late enrollee(s) n Existing member

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