ARTHRITIS/RHEUMATISM/JOINT PAIN/GOUT QUESTIONNAIRE

SOAL SELIDIK ATHRITIS/SAKIT RHEUMATIK/SAKIT SENDI/GOUT

(Swollen, painful joints, associated with restricted movement, fever, deformity of the joint)
(Bengkak, sakit sendi, berkaitan dengan pergerakan yang terbatas, demam, kecacatan pada sendi)

Proposal Number/Nombor Cadangan :

Name/Nama :

New NRIC No/Nombor KP Baru :

_____________________________________________________________________________________________________________________

1. Please tick the exact diagnosis as appropriate below/Sila tandakan diagnosis yang tepat yang mana berkaitan seperti di bawah
ini:

Gout [ ] Arthritis [ ] Rheumatism [ ] Joint Pain[ ]

Gout Athritis Sakit Rheumatik Sakit Sendi

2. Which joints are affected?/Sendi manakah yang terjejas?

3. When did you first notice to have the above problem?/Bilakah pertama kali anda mengalami masalah seperti di atas?

4. a. What is the cause?/Apakah puncanya?

b. Are you able to go about your daily activity without difficulty?/Adakah anda mampu menjalankan aktiviti harian anda
tanpa mengalami sebarang masalah?

[ ] Yes/Ya [ ] No/Tidak; Please give full details/Sila berikan butiran penuh.

c. Is there presently any limitation of movement or deformities?/Buat masa ini adakah terdapat sebarang pergerakan yang
terbatas atau kecacatan?

[ ] No/Tidak [ ] Yes/Ya; Please give full details/Sila berikan butiran penuh.

d. Any walking aids required?/Adakah alatan bantuan pergerakan diperlukan?

[ ] No/Tidak [ ] Yes/Ya; Please give full details/Sila berikan butiran penuh.

5. a. How many attacks have there been so far?/Berapakah jumlah serangan yang pernah dialami setakat ini?

b. When was the last attack?/Bilakah serangan yang terakhir? _____/_____/_______

c. Any injury resulted to the particular joint affected/Adakah sebarang kecederaan berlaku pada sendi tertentu yang terjejas.

[ ] No/Tidak [ ] Yes/Ya; Please give full details/Sila berikan butiran penuh.

______________________________________________________

______________________________________________________

[ 60301004 ]
 d. Any treatment received?/Adakah menerima sebarang rawatan?
[ ] No/Tidak
[ ] Yes/Ya; Type of treatment/ Jenis rawatan:
[ ] Physiotheraphy/ Rawatan fisioterapi
[ ] Surgery/ Pembedahan
[ ] Medication/Ubatan

Date/Tarikh: ____/_____/_______

Duration/Jangkamasa: ___________________

e. Type of medicine taken/Jenis ubat yang diambil:

Name/Nama Dosage/Dos Frequency/Kekerapan

Occsasional/ Continuos/ Frequent/
Kadang-kala Berterusan Selalu

___________ _______________ [ ] [ ] [ ]

___________ _______________ [ ] [ ] [ ]

f. Are you still on medication/treatment?/Adakah anda masih menerima rawatan?

[ ] No/Tidak [ ]Yes/Ya

6. Any confirmatory blood test/X-ray done?/Adakah sebarang ujian darah/x-ray dilakukan?

[ ] No/Tidak [ ]Yes/Ya; Please enclose reports/Sila lampirkan laporannya.

7. Please state name and address of doctor whom you usually consult and the last consultation date.
Sila nyatakan nama dan alamat doktor yang biasanya anda rujuk dan tarikh rujukan yang terakhir.

_____________________________________________________________________________________________________________________

I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material
information that may influence the assessment or acceptance of this proposal. I agree that this form will constitute part of my
proposal for family takaful and that failure to disclose any material facts known to me may invalidate the contract.

Saya mengaku bahawa jawapan yang telah saya berikan adalah, sepanjang pengetahuan saya, benar dan saya tidak
menyembunyikan sebarang maklumat penting yang mungkin akan mempengaruhi penilaian atau penerimaan cadangan takaful
ini. Saya bersetuju bahawa borang ini akan menjadi sebahagian dari borang cadangan untuk takaful keluarga dan kegagalan
untuk mendedahkan sebarang maklumat penting yang saya ketahui berkemungkinan membatalkan kontrak takaful tersebut.

Signed by/Ditandatangani oleh: _________________________ Date/Tarikh: