7787 med form-2026

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262 votes

The document is a medical assessment form for individuals aged 76 and above, used by Pacific Life Insurance Company. It includes sections for identifying objects, assessing physical and cognitive abilities, and recording responses to various health-related questions. The form aims to evaluate the proposed insured's mobility, daily living assistance needs, and cognitive function through specific inquiries and tasks.

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Click ‘Get Form’ to open the 7787 med form in the editor.
Begin by entering the Proposed Insured’s name, including first, middle initial, and last name, along with their date of birth in the specified format (mm/dd/yyyy).
In the Object Identification section, point to three objects and record their names in fields a, b, and c.
Proceed to answer the activity questions. For each question regarding exercise, work, driving, mobility issues, and cognitive disorders, select 'Yes' or 'No' and provide additional details in the Remarks section as needed.
For assistance/mobility questions, indicate if assistance is required for activities like bathing or dressing. Specify which activities need help in the Remarks section.
Record how long it takes for the Proposed Insured to complete a specific task by timing them and noting the duration in seconds.
Complete cognitive questions by asking about time-related information and recalling previously identified objects. Ensure to document responses accurately.
Finally, have the Proposed Insured sign at the designated area and fill out examiner's information including date and signature.

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Are you having any issues taking your medications? Are there any medication that you are not sure you should be taking? Are you taking all your meds as prescribed by your doctor? Are you taking any other medication or substances that have not been prescribed for you but you find helpful to take?

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What is an example of medication reconciliation?

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What is the medical verification form CW 61?

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7787 med form-2026

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