Personal Survey

Your Age

Age of Spouse

 Relationship Status:

Single
Married
Domestic Partner
Family Relationship

Have you ever known anyone who has needed long term care?

Yes
No

If yes, please explain:           

          

If you need long term care, please rank your most important concerns      (1 - 5, with 1 being the highest)

   Protect standard of living

   Freedom of choice

   Protection of assets

   Maintain independence

   Other    

If you need long term care today, how would you finance it?

Spend down assets
Income
Medicare
Medicaid
Long term care insurance
Other    

What part of any long term care risk would you be willing to bear?

None, I prefer full coverage
10 - 25%
25 - 50%
50 - 75%
75 - 100%

If you need long term care, please rank preference as to where you would most prefer receiving your care:

   Home

   Adult day care

   Assisted living facility

   Nursing home

Financial Survey

Projected monthly income at retirement (investment, SS, pension, other)

$2,500 - $4,000
$4,000 - $5,500
$5,500 - $7,000
$7,000 - $8,500
$8,500 +

Value of total assets to protect (exclusive of home, furnishings and automobile) 

up to $250,000
$250,000 - $500,000
$500,000 - $750,000
$750,000 +

Health Survey

   Your height

   and weight

Tobacco?

Yes
No

List all prescriptions taken within the last 12 months

   Spouse's height

   and weight

Tobacco?

Yes
No

List all prescriptions taken within the last 12 months