Pre-Planning Initial Consultation Step 1 of 5 20% 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 PhoneWork PhoneEmail* 1. Marital StatusMarriedSingleWidowedDivorcedChildren's Name/ Age (if any):NameDate of Birth click + button to add rows Pre-Screening Health Statement - Part A1. 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 BClient Full NameHeightWeight1. 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:MedicationDoseFrequencyReason click + button to add rowsComments:Spouse Full NameHeightWeight1. 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:MedicationDoseFrequencyReason click + button to add rowsComments: FINANCIAL INFORMATION1. Own Home? Yes No Home Value $2. Outstanding Mortgage $3. Own other property/real estate? Yes No DescriptionValue $Mortgage $Monthly Income:Type of IncomeClient IncomeSpouse 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 AccountOwner of AccountValue of Account click + button to add rowsTotal Checking/Savings ValueCD’s/Money MarketsOwner of AccountValue of Account click + button to add rowsTotal CD's/Money Markets ValueStocks/BondsOwner of AccountValue of AccountCost Basis click + button to add rowsTotal Stocks/Bonds ValueAnnuitiesOwnerValueCost BasisSurrender Value click + button to add rowsTotal Annuities ValueMutual FundsOwnerValue of AccountCost Basis click + button to add rowsTotal Mutual Funds ValueIRA'sOwnerInvestment TypeValue of AccountSurrender Value click + button to add rowsTotal IRA's Account Value401kOwnerInvestment TypeValue of AccountSurrender Value click + button to add rowsTotal 401k Account ValueIs owner of 401k account still working? Yes No Other/ Cash Value Life Ins.OwnerDeath BenefitCash ValueCash Surrender Value click + button to add rowsTOTAL Cash Value of Other/Cash Value Life Ins. Client Goals and Objectives1. 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 PhoneEmailCellphoneCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. REQUEST A FREE QUOTE! Get a Free Comprehensive Quote for Your Client Today! Free Client Quote REQUEST A FREE QUOTE! GET A FREE COMPREHENSIVE QUOTEFOR YOUR CLIENT TODAY! Free Client Quote HQ WealthMerge 906 McClain Rd., #3002Bentonville, AR 72712