DIABETES QUESTIONNAIRE

Name of Applicant:

Reference No.:

1. Please state the date diabetes was diagnosed. (MM/DD/YYYY)

2. Please provide full name and address of your regular doctor for diabetes and date(s) of consultation in
last 12 months.
Name of Doctor:
Address:
Date: (MM/DD/YYYY)
3. Is/ Are there any other doctor that you also consult in relation to diabetes?
[ ] Yes
If YES, please provide full name and address and date of consultation in last 12 months.
Name of Doctor:
Address:
Date: (MM/DD/YYYY)

[ ] No

4. Please state date and result of test/investigation done in relation to diabetes in last 12 months.
Date
Results
[ ]

Urine test for sugar

[ ]

Fasting blood glucose

[ ]

Glycosylated haemaglobin HbA1c

[ ]

Other blood test (e.g. lipids, renal function, etc)

[ ]

Others (please specify)

[ ]

No test

Please also provide the medical report copy.

5. Do you suffer from any of the following diseases?
If YES, please tick if appropriate.
[ ] Kidney disorder / abnormalities in urine (e.g. blood, protein, glucose, etc)
[ ] Heart, brain or circulatory disorder
[ ] Hypertension
[ ] Elevated cholesterol
[ ] Eye disorder

[ ] Yes

[ ] No

If any of above is ticked, please provide full details including the attending doctor full name and
address.

6. Have you been told that the diabetes is secondary to other reasons e.g. hypertension, heart disease
and kidney disease?
[ ] Yes [ ] No
If YES, please provide details.
I hereby declare and agree that the above particulars and answers are true, complete and correct. I also
understand that the Company believes them to be such, will rely and act on them, otherwise policy issued
hereunder may be void. The information provided by me together with the relevant policy issued shall
constitute the entire contract between myself and the Company.

Signature of Applicant
QR-UND-DMQ / REVISION 1 / JULY 2012

Soliciting Agent/Code No.

Date

PHILAM LIFE CUSTOMER CONFIDENTIAL