Diabetes Mellitus 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. Diabetes Mellitus Questionnaire

1.) What type of diabetes do you have ?
Type I or Insulin Dependent DM m m d d y y y y
Type II or Non-Insulin Dependent DM Date of Diagnosis: / /
Height and Weight at time of diagnosis: Height: feet inches Weight: pounds
Name of Attending Physician : Specialty of Attending Physician:
Clinic Address : Clinic Hours :
Contact number :
2.) How was the diagnosis of diabetes mellitus made ?

Blood sugar Test Made Urine Test Result

Diagnostic Test Performed Result Date of Test
m m d d y y y y
Fasting Blood Sugar (FBS) / /
Glycosylated Hemoglobin (Hba1C) / /
Urine Sugar / /
Albumin/ Protein / /
Signs and symptoms observed

3.) Current Attending Physician/s Details

Name of Attending Physician : Clinic Address : ____________________________
m m d d y y y y
Date of Last Consultation/ Check Up: / / Contact number: ____________________________
4.) What is your treatment regimen?
Diet Only Diet and Oral Medication Diet and Insulin Injection
Name of Drug Dosage Date Started
(include preparation) m m d d y y y y
/ /
/ /
/ /
5.) Do you exercise? Yes No If Yes, provide details below.
Type of Exercise: Number of Times a week:
6.) How often do you test your blood and urine sugar levels?
Number of times: in a day / week / month / year
Laboratory Test Date of Test Test Result
m m d d y y y y Please attach copy of result
/ /
/ /
/ /
Home Gadget Date of Test Test Result
m m d d
/ /
/ /
/ /
 7.) Have you ever been confined because of diabetes mellitus? 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 Admission: / / Date of Discharge: / /
Name of Medical Institution:
Address : Contact number:

Name of Attending Physician/s :

8.) Are you currently experiencing any of these?
Increased Urination Excessive thirst Increased Eating
Blurred vision Nausea, vomiting Drowsiness
Decreased endurance to exercise Pain in any part of the body Numbness or tingling sensations
Weight loss Fatigue on hands, feet or legs
9.) Do you smoke? Yes No If yes, provide details.
Number of years :
Number of sticks per day:
Type of Cigars smoked :
10.) Do you drink alcohol? Yes No If yes, provide details.
Number of years :
Number of glasses : per day / week / month
Type of Alcohol :
11.) Do you have any of the following or other existing medical condition?
Hypertension Retinopathy Coronary Heart Disease
Kidney Disease Hypo / hyperthyroidism Others. Please give details below:

12.) Is there anyone else in the family who has diabetes milletus? Yes No
If yes, provide degree of relationship.
13.) Are you scheduled to undergo any test or procedure in relation to diabetes mellitus or its complications ?
Yes No If yes, provide details.
Tests to be Performed Date of Test Test Requested by Test Result
m m d d y y y y
/ /
/ /
/ /
14.) Have you ever been absent or off from school or work due to diabetes mellitus? Yes No
If yes, please provide details below:
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 questionnaire are true and accurate representations of my health condition. Should FWD need additional information, I
hereby authorized the above mentioned physician, surgeon, or medical institution to provide FWD or its authorized representative, the Medical Information Bureau or any government
agency requiring such with information or documents pertaining to my health condition. Further, I am fully aware that statements made to this questionnaire shall form part of and be the
basis for the issuance of the policy bearing the same number as stated above.
m m d d y y y y
Place Signed Date: / /

Signature over Printed Name of Proposed Insured / Owner

DMQV206112014