GYNECOLOGICAL QUESTIONNAIRE

(Includes abnormal cervical/PAP smear, hysterectomy, menstrual problems, etc.)

APPLICANT'S NAME: ______________________________ FILE NO: ____________________

To assess your insurability, we require the following information:

Please complete all section(s) that apply to you. If the information is unknown to you, please contact your
doctor.

Abnormal cervical smear test

1. When was the first abnormal PAP? ___________________________________________________________________

2. Please provide the results of the PAP and the precise diagnosis. (i.e. CIN I, II, III) ______________________________
________________________________________________________________________________________________

3. Did you receive any treatment? Yes No If “yes”, provide details. _____________________________________
________________________________________________________________________________________________

4. Please provide the dates and results of your last 2 PAP tests. _______________________________________________
________________________________________________________________________________________________

5. Are you still being followed-up? Yes No

If “yes”, please state how often. ______________________________________________________________________
If “no”, when were you discharged from follow-up? ______________________________________________________

Hysterectomy
1. What was the reason you required a hysterectomy? (i.e.: bleeding, fibroids, tumor)
________________________________________________________________________________________________

2. What was the date of the Hysterectomy? _______________________________________________________________

3. Were the results confirmed to be: Benign? _____ Malignant? _____ Don’t Know: _____

4. Did you receive any treatment following your hysterectomy? Yes No If “yes”, what type of treatment did you
receive and for how long? _________________________________________________________________________

5. Did you receive any medication following your hysterectomy? Yes No If “yes”, what is the name of the
medication and the dosage taken daily? ________________________________________________________________

6. Are you still under any type of treatment or taking any medications? Yes No If “yes”, please provide details.
________________________________________________________________________________________________

7. Have there been any complications following the hysterectomy? Yes No If “yes”, please provide details.
________________________________________________________________________________________________

8. Have you lost significant time (i.e. weeks) off work with this condition? Yes No If “yes”, please provide details
including dates and duration of time off work. ___________________________________________________________
________________________________________________________________________________________________

9. Are you still being follow-up? Yes No

If “yes”, please state how often. ______________________________________________________________________
If “no”, when were you discharged from follow-up? ______________________________________________________
10. Do you consider yourself to be fully recovered? Yes No If “no”, please provide details.
________________________________________________________________________________________________

11. Are any further procedures, tests, treatments, medications or surgeries planned or anticipated? Yes No
If “yes”, what and when? ___________________________________________________________________________

Other gynecological problems

1. Please state the precise diagnosis (if unknown, please contact your doctor). ___________________________________

2. Were the results confirmed to be: Benign? _____ Malignant? _____ Don’t Know: _____

3. Regarding your symptoms:

(a) Please describe your symptoms. __________________________________________________________________
(b) When did your symptoms first occur? ______________________________________________________________
(c) How frequently do your symptoms occur? (i.e. how often in the last 12 months) ____________________________
(d) When was the last occurrence of your symptoms? ____________________________________________________

4. (a) Have you had surgery? Yes No If “yes”, please provide date(s) and full details.
____________________________________________________________________________________________
(b) Is surgery being considered? Yes No If “yes”, please provide date(s) and full details.
____________________________________________________________________________________________

5. Are you receiving any current treatment and/or medication? Yes No If “yes”, please provide the names of the
medication, the dosage and how often taken. ___________________________________________________________
_______________________________________________________________________________________________

6. Are you still being followed-up? Yes No

If “yes”, please state how often. _____________________________________________________________________
If “no”, when were you discharged from follow-up? _____________________________________________________

I DECLARE THAT THE ABOVE INFORMATION IS TRUE AND COMPLETE AND SHALL FORM PART OF
MY APPLICATION TO CUMIS LIFE INSURANCE COMPANY. I UNDERSTAND THAT THE PERSONAL
INFORMATION FURNISHED ON THIS FORM WILL BE USED BY CUMIS FOR UNDERWRITING
PURPOSES, AND FOR SUCH OTHER LAWFUL PURPOSES IN ACCORDANCE WITH APPLICABLE
FEDERAL AND PROVINCIAL LAWS, AS MAY APPLY.

If this document is signed and delivered by fax, it will be for all purposes considered an original document.

DATE: ____________________________ SIGNATURE _________________________________________________