Pre-Planning Initial Consultation

Name*
First Last
Spouse, If married:
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Spouse's Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address City ZIP Code
State*
Home Phone*
Cell Phone
Work Phone
Email*
1. Marital Status
- Married
- Single
- Widowed
- Divorced
Children's Name/ Age (if any):
Name Date of Birth

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Pre-Screening Health Statement - Part A
1. Within the past two years have you been confined to a nursing home, assisted living center, received or been advised to receive hospice care, been advised that you have a terminal illness or need assistance with: bathing, eating, dressing, toileting, transferring into and out of bed, chair, or wheelchair and/or maintain continence?
Client? (Yes or No) Spouse (if applicable)? (Yes or No)
2. Are you currently hospitalized, bedridden or use medical devices such as: wheelchair, walker, dialysis machine, oxygen equipment, respirator, stair lift, chair lift, motorized scooter or taking medications Aricept, Exelon, Reminyl or Namenda?
Client? (Yes or No) Spouse (if applicable)? (Yes or No)
3. Have you ever been diagnosed by a member of the medical profession as having AIDS, HIV, or ARC disorders, or tested positive for antibodies for the AIDS virus?
Client? (Yes or No) Spouse (if applicable)? (Yes or No)
4. If under the age of 65, is there any reason you are not physically and mentally capable of active employment or are you currently receiving or have received within the past five years social security disability income benefits?
Client? (Yes or No) Spouse (if applicable)? (Yes or No)
5. Have you ever been diagnosed, treated, tested positive for, or been given professional medical advice for: Alzheimer’s disease, dementia, memory loss, multiple sclerosis, muscular dystrophy, ALS (Lou Gehrig’s disease) Parkinson’s disease, down syndrome, organ transplant (other than kidney) or active cancer?
Client? (Yes or No) Spouse (if applicable)? (Yes or No)

Client and Spouse Pre-Screening Health Statement - Part B
Client Full Name
Height
Weight
1. In the past 5 years, is there a history of:
- Diabetes
- Leukemia
- Heart Disease
- Heart Attack
- Stroke
- Depression
- Congestive Heart Failure
- Cardiomyopathy
- Uncontrolled High Blood Pressure
- Amyotrophic Lateral Sclerosis (ALS)
- Cancer
- Organ Failure/Disease
- Chronic Obstructive Lung Disease (COLD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Alcohol/Drug Abuse
Other history :
List Medications:
Medication Dose Frequency Reason

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Comments:
Spouse Full Name
Height
Weight
1. In the past 5 years, is there a history of:
- Diabetes
- Leukemia
- Heart Disease
- Heart Attack
- Stroke
- Depression
- Congestive Heart Failure
- Cardiomyopathy
- Uncontrolled High Blood Pressure
- Amyotrophic Lateral Sclerosis (ALS)
- Cancer
- Organ Failure/Disease
- Chronic Obstructive Lung Disease (COLD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Alcohol/Drug Abuse
Other history :
List Medications:
Medication Dose Frequency Reason

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Comments:

FINANCIAL INFORMATION
1. Own Home?
- Yes
- No
Home Value $
2. Outstanding Mortgage $
3. Own other property/real estate?
- Yes
- No
Description
Value $
Mortgage $
Monthly Income:
Type of Income Client Income Spouse Income

List all type of Incomes below such as Social Security, Gross Wages, Pensions, Spousal Pension Continuation Benefit, Military Retirement, Interest/Dividends, Investment Property ,Income from IRA’s, and Others
Do you rely on IRA Income for living expenses?
- Yes
- No
6. Assets:
Checking / Savings Account Owner of Account Value of Account

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Total Checking/Savings Value
CD’s/Money Markets Owner of Account Value of Account

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Total CD's/Money Markets Value
Stocks/Bonds Owner of Account Value of Account Cost Basis

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Total Stocks/Bonds Value
Annuities Owner Value Cost Basis Surrender Value

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Total Annuities Value
Mutual Funds Owner Value of Account Cost Basis

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Total Mutual Funds Value
IRA's Owner Investment Type Value of Account Surrender Value

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Total IRA's Account Value
401k Owner Investment Type Value of Account Surrender Value

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Total 401k Account Value
Is owner of 401k account still working?
- Yes
- No
Other/ Cash Value Life Ins. Owner Death Benefit Cash Value Cash Surrender Value

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TOTAL Cash Value of Other/Cash Value Life Ins.

Client Goals and Objectives
1. Is there a Long-Term Care Insurance Plan in place?
- Yes
- No
Total Benefit Amount $
Daily Benefit Amount $
2. If you get sick and need LTC, where would you want to receive care?
- At home
- Assisted Living
- Nursing Home
Please tell us what you are hoping to accomplish for your client with this plan?
Are there any special circumstances we should be aware of as we design this plan, e.g. client likes, dislikes, or any factors we should be aware of that will make this plan the perfect for for your clients?
Who is the primary contact in your law office in case we have any questions about this fact finder?
What is the best way to reach him/her?
- Phone
- Email
- Cell Phone
Phone Email Cellphone
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Phone
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Pre-Planning Initial Consultation

Step 1 of 5

Pre-Screening Health Statement - Part A

Client and Spouse Pre-Screening Health Statement - Part B

FINANCIAL INFORMATION

Client Goals and Objectives

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Other/ Cash Value Life Ins.	Owner	Death Benefit	Cash Value	Cash Surrender Value

Name	Date of Birth

Medication	Dose	Frequency	Reason

Medication	Dose	Frequency	Reason

Type of Income	Client Income	Spouse Income