HTML Preview Health Questionnaire page number 1.
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
service mark of Health Net, Inc. All rights reserved.
Check one
n Initial enrollee n Late enrollee(s) n Existing member