Fact Finder - Page 1 of 10

Your Information

Name:
Date of Birth	/ /
Occupation	Retired Working
Smoking	Non-smoker Smoker
Marital Status	Married Single Widowed Divorced
Home Street Address
City, State, Zip:	,
Home Phone	() -
Work Phone	() -
Cell Phone	() -
E-Mail Address:

Your Health

Are you currently being treated by a physician?	Yes No
Treatments:
Are you currently taking any medications?	Yes No
Medications:
Physician's Name:
Physician's Phone Number:	() -

Spouse's Information

Name:
Date of Birth:	/ /
Occupation	Retired Working
Smoking:	Non-smoker Smoker
Cell Phone	() -
E-Mail Address:

Spouse's Health

Is your spouse currently being treated by a physician?	Yes No
Treatments:
Is your spouse currently taking any medications?	Yes No
Medications:
Spouse's Physician's Name:
Spouse's Physician's Phone Number:	() -

Children

Name	Age	Resident State	Financial Position	Special Needs

Do you have grandchildren?	Yes No
How Many?
Ages:

Income

	Husband	Wife
Social Security	$	$
Pension	$	$
Total Annual Unearned Income	$	$
Total Earned Income	$	$
Income Required Monthly	$	$

7941 Ravenna Rd., Hudson, OH 44236, (330) 656-0007.
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