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Healthcare Retirement Secrets Questionnaire
Please fill out this form to help me understand better your current goals, needs, and challenges.
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Email *
Your Name (First Name, Last Name) *
What is your current marital status? *
What is your birthday? *
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Your Phone or Mobile Number *
Your Mailing Address *
What is your preferred method of contact? *
Do you have health insurance coverage now?  If yes, what is the policy? *
Do you have a primary care provider? *
Do you see a specialist regularly? *
If you answered yes to the previous question, who is your specialist and what is his/her specialty? (Optional)
Do you take medications regularly? *
Do you spend more than $100 per month on medications? *
Where is your preferred pharmacy? *
Have you been hospitalized in the last 12 months? *
Are you currently employed full time? *
Do you also have a part-time job?
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Do you plan on continuing to work after 65? *
Please choose your approximate annual income range: *
Do you file taxes jointly or individually? If you answered jointly, when is your spouse’s birthday? *
How often do you travel and is it ever out of the country? *
Do you have a Flexible Spending Account (FSA), Health Savings Account (HSA), or a Health Reimbursement Account (HRA)?  If so, which? Check the applicable box(es). *
Required
Do you have a life insurance policy? If so, what kind?  Term, Whole, Final Expense, etc. *
Do you have a long-term care policy? *
Do you have a 401-K, IRA or Roth IRA? Check the applicable box(es). *
Required
What are some specific questions you have regarding Medicare? *
How did the Financial Crisis of 2008 affect your retirement planning? *
How has the COVID-19 pandemic affected you personally and financially? *
Do you have children?  If so, how many? *
If you have grandchildren, where do they live? (Optional)
How do you envision your optimal retirement and what does it look like financially? *
Have you developed a last will and testament? *
Are there any family history of medical conditions? *
Do you have a medical condition now that could develop into something more chronic in the future?  (e.g., diabetes, heart disease, COPD, etc.) *
Did you have a family member suffer with Alzheimer’s Disease or Dementia? If yes, did they require nursing home or memory care services? *
What is your greatest fear in retirement with regards to finances? *
Do you have any additional questions for us?   *
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