iman AUSTRALIAN HEALTH PLANS Policy Number (if applicable): Name: Date of Birth: Address: Have you experienced any of the following: (\f yes, please include details of condition): 41. Diabetes, high blood sugar, sugar in the urine Yes/ No 2. Injury to, or disorder of any joint, muscle or ligament Yes/ No 3. Any heart or circulatory condition, including but not limited to, high blood pressure, irregular heartbeat, heart attack or chest pain Yes/No 4. any type of cancer, tumour or blood disorder Yes/No 5. Any nervous disorder or mental health condition Yes/No 6. Any other medical condition requiring ongoing monitoring or treatment Yes/No In the last 5 years have you or any other person in the pol 41. Been admitted to hospital for any reason Yes/No 2. Taken any medication, other than the contraceptive pill or for cold or flu Yes/No 3. Experienced any symptoms, or sought advice or treatment from any medical specialist for anything other than already answered above Yes/No THIS SECTION MUST BE COMPLETED, DATED AND SIGNED | HAVE READ AND UNDERSTOOD THE ADVICE REGARDING EXISTING AILMENTS AND HAVE COMPLETED THE EXISTING AILMENTS QUESTIONNAIRE. We may reduce or refuse to pay a claim, or cancel the policy if you have not answered the questions or fail to deciare any pre-existing condition. Name (Parent of a dependent child must sign) Signed a Date MAN Austaan Hoa Pane subsidiary oni heaingstinted | ABNSE 146 007 746 | Looked a9 2010, Neweaste NSW 2300, ya00 221198 | t 66894914 191 | 1461260209888 | @ efoRaueestncom | w auch zm ——