Arthritis Disorder Questionnaire for Proposed Insured/Owner

Policy Number
Please fill in block letters & tick appropriate boxes and circles.
A. Personal Information of Proposed Insured / Owner
Last Name First Name Ext Name Middle Name

m m d d y y y y
Date of Birth: / /

B. Arthritis Questionnaire
1.) When was the diagnosis of arthritis made?
m m d d y y y y
Date of Diagnosis: / /

Name of Attending Physician : ___________________________ Specialty of Attending Physician: __________________

Clinic Address : _____________________________________ Clinic Hours : _____________________________________
Contact number: _____________________________________
2.) How often do you have arthritis attacks and what triggers it? Please provide details below:
Number of times: in a day / week / month / year
Trigger: _________________________________________________________________________________________________
3.) Have you ever been confined because of arthritis ? Yes No If Yes, provide details below.
m m d d y y y y m m d d y y y y
Date of Confinement: / / Date of Discharge: / /
Name of Medical Institution:
Address : ______________________________________________ Contact number:
Name of Attending Physician/s :
4.) What are your medications?
Name of Drug Dosage Date Started
(include preparation) m m d d y y y y
/ /

/ /

/ /

5.) Do you have any other existing medical condition or disease? Yes No If yes, please give details below:
_________________________________________________________________________________________________________
6.) Do you smoke? Yes No If yes, provide details below .
Number of years :
Number of sticks per day:
Type of Cigars smoked :
7.) Have you ever been absent or off from school or work due to arthritis condition? Yes No
m m d d y y y y
Number of times in a year: Date of last occurrence: / /

C. Affirmation Section
I hereby declare that the answers/statements that I have made to this questio nnaire are true and accurate representatio ns o f my health co nditio n. Sho uld FWD need additio nal info rmatio n,
I hereby autho rized the abo ve mentio ned physician, surgeo n, o r medical institutio n to pro vide FWD o r its autho rized representative, the M edical Info rmatio n B ureau o r any go vernment
agency requiring such with info rmatio n o r do cuments pertaining to my health co nditio n. Further, I am fully aware that statements made to this questio nnaire shall fo rm part o f and be the
basis fo r the issuance o f the po licy bearing the same number as stated abo ve.
m m d d y y y y
Place Signed Date: / /

Signature over Printed Name of Proposed Insured / Owner

ARQV206112014