Hypertension 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. Hypertension Questionnaire
1.) When was hypertension first discovered?
m m d d y y y y
Date of Diagnosis: / /
Name of Attending Physician : _______________________________ Specialty of Attending Physician: _________________
2.) What were the Blood Pressure readings?
_______________________________________________________________________________________________________
3.) Is there any underlying cause? Yes No If yes, provide details. _________________________________________
4.) Are there any complications? Yes No If yes, provide details. _________________________________________
5.) Have you ever been confined because of Hypertension? Yes No
If yes, please answer the following:
m m d d y y y y m m d d y y y y
Date of Confinement: / / Date of Discharge: / /

Name of Attending Physician/s: ______________________________________________________

m m d d y y y y
Date of last consultation or check-up: / /
6.) What are your medications? __________________________________________________________
Name of Drug Dosage Date Started
(include Preparation) m m d d y y y y
__________________________________________ _______________________ / /
__________________________________________ _______________________ / /
__________________________________________ _______________________ / /
7.) Do you smoke? Yes No If yes, provide details.
Number of years: _________________________
Number of sticks per day: _________________________
Type of Cigars smoked: _________________________
8.) Do you have any other existing medical condition or disease? Yes No If yes, provide details.
_________________________________________________________________________________________________
9.) Is there anyone else in the family who has hypertension? Yes No
If yes, please indicate degree of relationship _____________________________________________________________
10.)Have you ever been absent or off from school or work due to Hypertension 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

HPNQV206112014