General
Edited:
I require prescription medication daily for this condition.
Simplified: I have prescription medication for this condition.
Opening Questions
Removed:
I have received medical or mental health care related to my gender identity.
I will require medical care or support related to my gender identity.
Edited:
Do you take immunosuppressive/immunomodulator medications for a chronic medical condition (including chronic steroids)?
Clarified: Do you take immunosuppressive/immunomodulator medications for a chronic medical condition (e.g., steroids, Humira, Enbrel, Remicade)?
I can hold a squat position for several minutes to use a squat commode or toilet.
Simplified: I can hold a squat position for several minutes to use a squat commode.
Allergy Body System
Removed:
My treatment requires a prescription medication on most days.
I use over-the-counter medication to treat my allergies
Edited:
Allergy shot
Clarified: Allergy desensitization treatment
I have an inhaler to use during an allergic reaction.
Clarified: I have an inhaler to use during a peanut allergic reaction. I have an inhaler to use during an allergic reaction to other nuts. I have an inhaler to use during a shellfish allergic reaction. I have an inhaler to use during an egg or egg protein allergic reaction. I have an inhaler to use during an allergic reaction to other foods. I have an inhaler to use during an allergic reaction to animals. I have an inhaler to use during an allergic reaction to insect allergens. I have an inhaler to use during an allergic reaction to environmental allergens. I have an inhaler to use during an allergic reaction to seasonal allergens.
Cardiovascular
Removed:
For questions related to High cholesterol or high triglycerides:
I require a specialist for monitoring and/or follow-up for this condition.
For questions related to Raynaud’s syndrome:
I require a specialist for monitoring and/or follow-up for this condition
For final question related to Any cardiac condition:
The condition causing my symptoms is not known and I do not have a diagnosis.
Describe symptoms: Date of initial symptoms:
Edited:
Stroke or stroke-like symptoms
Clarified: Stroke or stroke-like symptoms (e.g., Transient ischemic attack [TIA])
Any cardiac symptoms (e.g., fainting or chest pain), diagnosed condition, or cardiac surgery not previously listed.
Simplified: Any cardiac condition not previously listed for which you have sought medical attention in the past two years.
I was given a diagnosis for my symptoms. Diagnosis:
Simplified: Describe:
Dermatology
Removed:
For final question related to Any skin condition:
The condition causing my symptoms is not known and I do not have a diagnosis.
Describe symptoms: Date of initial symptoms:
Edited:
Location and extent:
Simplified: Extent
Any skin symptom (e.g., a rash, itching, or dry skin), diagnosed condition, or skin surgery not previously listed.
Simplified: Any skin condition not previously listed for which you have sought medical attention in the past two years.
For questions related to Any skin condition:
I was given a diagnosis for my symptoms. Diagnosis:
Simplified: Describe:
Endocrinology
Removed:
Hyperthyroidism or Grave’s Disease
Hypothyroidism (underactive thyroid)
Acromegaly (growth hormone secreting pituitary tumor)
Prolactin-secreting pituitary tumor (abnormal milk production in women)
Non-functioning (no production of hormones) pituitary tumor
Pheochromocytoma
For final question related to Any endocrinology condition:
The condition causing my symptoms is not known and I do not have a diagnosis.
Describe symptoms: Date of initial symptoms:
Edited:
Any endocrine symptom (e.g., hormonal abnormalities), diagnosed condition, or endocrine surgery not previously listed for which you have sought medical attention in the past two years.
Simplified: Any endocrine condition not previously listed for which you have sought medical attention in the past two years.
For questions related to High cholesterol or high triglycerides:
I was given a diagnosis for my symptoms. Diagnosis:
Simplified: Describe:
Ear, Nose and Throat
Removed:
For questions related to hard of hearing:
List type, date of purchase, manufacturer, model number, and replacement plan, if any.
I only require use of a hearing aid(s) in certain situations. Please provide examples:
My hearing aid(s) may need to be replaced in the next three years.
Date of expected future replacement and what is your plan?
For questions related to cochlear implant:
I only require use of a cochlear implant sound processor(s) in certain situations rather than daily.
For questions related to chronic ear infection and chronic sinusitis:
I currently have moderate to severe symptoms that affect my daily life. Describe symptoms:
Ear, nose, or throat surgery (e.g., ear, nose, mouth, tongue, throat, salivary glands, vocal cords, or neck)
Recurrent throat infections (e.g., strep, thrush, oral ulcers of mouth, tongue or throat)
Recurrent nose bleeds (without trauma)
For final question related to Any ear, nose, or throat condition:
The condition causing my symptoms is not known and I do not have a diagnosis.
Describe symptoms: Date of initial symptoms:
Edited:
I require the daily use of a hearing aid(s).
Simplified: I use hearing aid(s).
For questions related to cancer or malignancy of the throat, mouth, tongue, salivary glands, neck. Actual diagnosis:
Simplified: Describe:
Chronic ear infection
Clarified: Chronic/recurrent ear infection
Chronic sinusitis
Clarified: Chronic/recurrent sinusitis
Any other symptom or condition of the ear, nose, or throat (including surgeries) not previously listed that has required you to seek medical attention in the past two years.
Simplified: Any other ear, nose, or throat condition not previously listed that has required you to seek medical attention in the past two years.
I was given a diagnosis for my symptoms. Diagnosis:
Simplified: Describe:
I currently have moderate to severe symptoms that affect my daily life.
Simplified: I currently have symptoms that affect my daily life.
Gastroenterology
Removed:
Gastrointestinal surgery (e.g., esophagus, stomach, gall bladder, intestine, intestinal wall, anus, or rectum)
For questions related to acute pancreatitis: I am currently being treated for this condition. Describe:
For questions related to lactose intolerance and gluten intolerance: I have been diagnosed by a health-care provider with lactose intolerance. Date of diagnosis:
For questions related to acute pancreatitis: How are you currently managing this condition? I have prescription medication for this condition. I require a specialist for monitoring and/or follow-up for this condition. Describe:
For questions related to chronic or recurrent abdominal pain and any other intestinal, stomach, pancreas, or liver condition: The condition causing my symptoms is not known and I do not have a diagnosis. Describe symptoms: Date of initial symptoms:
Edited:
Any other diseases of liver or abnormal liver tests (e.g., Gilbert disease, fatty liver, alcohol-related liver injury, sarcoid liver, malaria, parasitic disease, or gall bladder-related issues).
Simplified: Any other diseases of liver (e.g., Gilbert disease, fatty liver, alcohol-related liver injury, sarcoid liver, malaria, parasitic disease, or gall bladder-related issues).
Gastrointestinal bleeding such as vomiting blood or blood in stools (e.g., gastritis, peptic ulcer disease, esophageal varices/tears, hemorrhoids, or other with text box)
Simplified: Gastrointestinal condition that caused bleeding (e.g., gastritis, peptic ulcer disease, esophageal varices/tears, hemorrhoids, or other)
Chronic or recurrent abdominal pain (check only if you have not already reported this condition above). I was given a diagnosis for my symptoms. Diagnosis:
Simplified: Describe:
Any other intestinal, stomach, pancreas, or liver condition (including surgeries) not previously listed for which you have sought medical attention in the past two years.
Simplified: Any other intestinal, stomach, pancreas, or liver condition not previously listed for which you have sought medical attention in the past two years.
I was given a diagnosis for my symptoms. Diagnosis: (Any other intestinal, stomach, pancreas, or liver condition)
Simplified: Describe:
Gynecology
Removed:
History of gynecological or breast surgeries
I am over 50 and I have had a mammogram. Date of last mammogram: Result of mammogram: Normal. Abnormal.
Date of last mammogram: Result of mammogram: Normal. Abnormal. (I am under 50 and I have had a mammogram or sonogram.
Diagnosis: Date of surgery: (I no longer have a cervix)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Abnormal menses)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Breast lump)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Polycystic ovarian disease)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Ovarian cyst)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Endometriosis)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Endometrial hyperplasia)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Infected Bartholin cysts)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Genital herpes)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Genital warts)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Fibroids)
I require a specialist for monitoring and/or follow-up for this condition. Do NOT check this box for regular visits to the doctor for routine Pap or mammogram visits. (Any gynecological condition)
Edited:
For questions related to abnormal menses: I have been given a diagnosis for this condition. Diagnosis:
Simplified: Describe:
Any gynecological symptom, diagnosed condition, or gynecological surgery not previously listed for which you have sought medical attention in the past two years (e.g., ectopic pregnancy, pelvic mass, uterine prolapse, uterine fibroids), excluding easily treated sexually transmitted diseases. Diagnosis:
Simplified: Any gynecological condition not previously listed for which you have sought medical attention in the past two years (e.g., ectopic pregnancy, pelvic mass, uterine prolapse, uterine fibroids), excluding easily treated sexually transmitted diseases. Describe:
Hematology
Removed:
For questions related to my spleen has been surgically removed: diagnosis (reason for non-functioning): Date of diagnosis:
A sub-questions removed except for date of diagnosis (Hemolytic anemia)
For questions related to any other blood disorder: I am currently being treated for this condition. Describe:
For final question related to Any other blood or lymphatic system condition:
The condition causing my symptoms is not known and I do not have a diagnosis.
Describe symptoms: Date of initial symptoms:
Edited:
My spleen has been surgically removed or is non-functioning.
Simplified: My spleen has been surgically removed
Essential (primary) thrombocytopenia
Simplified: Thrombocytopenia (low platelets)
Sickle cell disease or sickle cell trait
Edit: Separated for clarity
Hemolytic anemia (breakdown of red blood cells to a disease process)
Simplified: Hemolytic anemia and Date of diagnosis:
Polycythemia vera (high red blood cell count)
Simplified: Polycythemia (high red blood cell count)
Aplastic anemia (decreased stem cell production)
Simplified: Aplastic anemia
Anemia, Iron deficiency anemia, Vitamin B-12 or folate deficiency (megaloblastic/pernicious anemia), Anemia caused by another condition (e.g., kidney disease), Anemia caused by blood loss (e.g., heavy menses, bleeding ulcer), A bleeding problem due to a specific medication
Simplified (one question): Anemia (e.g., iron deficiency, pernicious anemia) with sub-questions including diagnosis, date of diagnosis, I am currently being treated for this condition.
Any other symptom, diagnosed condition, or surgery of the blood or lymphatic system not previously listed for which you have sought medical attention in the past two years.
Simplified: Any other blood or lymphatic system condition not previously listed for which you have sought medical attention in the past two years. Describe:
Infectious Disease
Removed:
Chancroid
For questions related to chronic, frequent, or recurrent bacterial, fungal, viral infection, including thrush: I am currently being treated for this condition. (Chronic, frequent, or recurrent bacterial, fungal, viral infection, including thrush)
For final question related to any other infectious disease:
The condition causing my symptoms is not known and I do not have a diagnosis.
Describe symptoms: Date of initial symptoms:
Edited:
Any other infectious disease condition or symptom (e.g., dengue, Lyme, malaria, Zika, amoeba, giardia) or any viral syndromes (e.g., mononucleosis, Epstein Barr virus, cytomegalovirus) not previously listed for which you have sought medical attention in the past two years (does not include self-limiting conditions such as a cold, flu, or simple infections)
Simplified: Any other infectious disease (e.g., dengue, Lyme, malaria, Zika, amoeba, giardia) or any viral syndromes (e.g., mononucleosis, Epstein Barr virus, cytomegalovirus) not previously listed for which you have sought medical attention in the past two years (does not include self-limiting conditions such as a cold, flu, or simple infections)
Mental Health
Removed:
Removed “e.g.,” throughout (grammar issue)
Edited:
Replaced “etc.” throughout with “other” (grammar issue)
Musculoskeletal
Removed:
For questions related to orthopedic surgery: I am currently being treated for this condition.
I have functional limitation(s) or restriction(s) related to conditions of the muscle, bone, tendon, or ligament condition (Note to applicant: be sure you have selected the related diagnosis and/or associated condition). I require medical equipment (brace, mobility assistive devices).
For questions related to Related to back, neck, skull, knee, shoulder, hand or wrist, hip or pelvis, foot or ankle, elbow, arm, leg, fingers, toes, muscle, bone, tendon or ligament question’s and the final question for any other bone, tendon or ligament: The condition causing my symptoms is not known and I do not have a diagnosis. Describe symptoms: Date of initial symptoms: I had surgery for this condition. Date of surgery:
For questions related to degenerative disc diseaseI have had a fracture in my lifetime due to this condition. Date(s), location(s) of fracture:
For questions related to degenerative joint disease: I sometimes experience numbness or pain in my leg or arm because of a compressed nerve in my neck or back. I have had a fracture in my lifetime due to this condition. Date(s), location(s) of fracture:
I have had a fracture in my lifetime due to this condition. Date(s), location(s) of fracture:
Edited:
I have a history of non-cancerous bone tumors or other diseases of the bone (e.g., Paget’s disease, fibrous dysplasia)
Simplified: Non-cancerous bone tumors or other diseases of the bone (e.g., Paget’s disease, fibrous dysplasia)
I have had orthopedic surgery and hardware (e.g., pins, rods, joint replacement) was left in place.
Simplified: Orthopedic surgery with retained hardware (e.g., pins, rods, joint replacement).
Describe the type of surgery(ies), reason for surgery(ies), and what hardware was left in place.
Simplified: Location:
For questions related to the back, neck, skull, knee, shoulder, hand or wrist, hip or pelvis, foot or ankle, elbow, arm, leg, fingers, toes, muscle, bone, tendon or ligament : Ay injury, surgery, or pain (on a regular or intermittent basis), or medical care sought for any reason, in relation to the X. The condition causing my symptoms is not known and I do not have a diagnosis. Describe symptoms: Date of initial symptoms:
Simplified: Any injury, pain (regular or intermittent basis), or medical care/treatment sought for any reason, in relation to the X. Describe:
For questions related to osteoporosis or osteopenia: I have had a fracture in my lifetime due to this condition. Date(s), location(s) of fracture:
Simplified: I have had a fracture due to this condition.
Any other muscle, bone, tendon, or ligament symptom, diagnosed condition, or orthopedic surgery not previously listed for which you have sought medical attention in the past two years.
Simplified: Any other muscle, bone, tendon, or ligament condition not previously listed for which you have sought medical attention in the past two years.
Neurology
Remove:
For questions related any other condition of brain or nervous system:
The condition causing my symptoms is not known and I do not have a diagnosis. Describe symptoms: Date of initial symptoms:
Edited:
Any diagnosis/treatment for concussion, head trauma, or brain injury
Simplified: Any diagnosis/treatment for concussion or traumatic brain injury
Have you had episode(s) of syncope (loss of consciousness or fainting) in the past two years?
Simplified: Have you had episode(s) of loss of consciousness or fainting in the past two years?
Any other symptom, condition, or surgery of the brain or nervous system (e.g., Guillain-Barre, peripheral neuropathy) for which you have sought medical attention in the past two years.
Simplified: Any other brain or nervous system condition (e.g., Guillain-Barre, peripheral neuropathy) not previously listed for which you have sought medical attention in the past two years.
Ophthalmology
Removed:
Ophthalmologic (eye) surgery
For questions related to lattice degeneration and retinitis pigmentosa: I require a specialist for monitoring and/or follow-up for this condition.
For questions related to cataract or any other eye condition: I had surgery due to this condition. Date of surgery: I have been told I need, or may need, surgery in the future due to this condition. I have some limitation with my eyesight due to this condition (such as night blindness). I require a specialist for monitoring and/or follow-up for this condition.
For questions related glaucoma: I require a specialist for monitoring and/or follow-up for this condition. I was given a diagnosis for my symptoms. List diagnosis: The condition causing my symptoms is not known and I do not have a diagnosis. Describe symptoms: Date of initial symptoms:
For questions related to any other eye condition: The cause of this condition is known and can be prevented.
Edited:
I have some limitation with my eyesight due to this condition (such as night blindness).
Clarified: I have some limitation with my activities of daily living due to this condition (such as night blindness).
I have some limitation with my eyesight due to this condition.
Clarified: I have some limitation with my activities of daily living due to this condition.
Any other eye symptom, diagnosed condition, or eye surgery not previously listed for which you have sought medical attention in the past two years
Simplified: Any other eye condition not previously listed for which you have sought medical attention in the past two years.
Respiratory
Removed:
For questions related to cystic fibrosis: The cause of this condition is known and can be prevented. (Cystic fibrosis)
For questions related to any other respiratory condition: I was given a diagnosis for my symptoms. List diagnosis: The condition causing my symptoms is not known and I do not have a diagnosis. Describe symptoms: Date of initial symptoms:
I had surgery due to this condition.
Edited:
Any other respiratory symptom, condition, or surgery not previously listed for which you have sought medical attention in the past two years.
Simplified: Any other respiratory condition not previously listed for which you have sought medical attention in the past two years.
Rheumatology and Immunology
Removed:
For questions related to any other rheumatoid or immunologic condtion: I was given a diagnosis for my symptoms. List diagnosis: The condition causing my symptoms is not known and I do not have a diagnosis. Describe symptoms: Date of initial symptoms:
Edited:
Any rheumatoid or immunologic symptom, diagnosed condition, or surgery not previously listed for which you have sought medical attention in the past two years.
Simplified: Any rheumatoid or immunologic condition not previously listed for which you have sought medical attention in the past two years.
Urology and Nephrology
Removed:
Any other urologic or nephrology surgery (e.g., kidneys, ureters, bladder, urethra, or testes)
For questions related to solitary or horseshoe kidney: I have had surgery for this condition. Reason for surgery: I am currently being treated for this condition.
For questions related to Solitary or horseshoe kidney and Polycystic kidney disease and Glomerulonephritis and Renal failure and Chronic bladder or pelvic pain and Any other abnormalities of the genitourinary tract and Genital herpes I require a specialist for monitoring and/or follow-up for this condition.
For questions related to recurrent cystitis, recurrent pyelonephritis, or other recurrent infections: Date of initial diagnosis (Recurrent cystitis, recurrent pyelonephritis, or other recurrent infections)
For questions related to any other abnormalities of the genitourinary tract (female): Abnormality of the urinary tract
Edited:
Cancer or carcinoma of the urinary tract, bladder, or kidney
Simplified: Cancer of the urinary tract, bladder, or kidney and prostate added to diagnosis list.
Any other kidney, bladder, urinary tract symptoms, or condition of the genitourinary system not previously listed for which you have sought medical attention in the past two years.
Simplified: Any other kidney, bladder or urinary tract condition not previously listed for which you have sought medical attention in the past two years.
Closing Questions
Edited:
I use medical equipment (either daily or as needed) that has not been previously listed.
Added: Cochlear implant to list
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ladd, Janet |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |