BACKACHE QUESTIONNAIRE

SOAL SELIDIK SAKIT BELAKANG

Proposal Number / Nombor Cadangan : 200475354

Name / Nama : WAN SAIFUL ANUAR BIN MOHAMED

New NRIC No / Nombor KP Baru : 840526106005

____________________________________________________________________________________________________________

1. When did you first have backache?/Bilakah anda mula mengalami sakit belakang?

2. a. How many attacks have you had in the past 2 years?

Dalam tempoh 2 tahun yang lepas, berapa kalikah anda diserang sakit belakang?

Year/Tahun Number of attacks/Jumlah serangan

___________ _________________

___________ _________________

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

3. Did you consult any doctor concerning it? If so, please state name and address of the doctor and the last consultation date.
Adakah anda merujuk kepada mana-mana doktor berkenaannya? Jika ada, sila nyatakan nama, alamat doktor dan tarikh
terakhir pertemuan tersebut.
[ ]No/Tidak [ ]Yes/Ya;

a. Name & address of doctor/Nama & alamat doctor:

________________________________________

________________________________________

b. Date of last consultation /Tarikh susulan terakhir:

__________________

c. What was the doctor’s advice?/Apakah nasihat doctor?

____________________________________________

4. Were any investigation done eg. X-ray etc? If so, please give full details eg. nature of the test done, result and date. Adakah ada
sebarang penyiasatan dilakukan, contohnya seperti x-ray dan sebagainya? Jika ada, sila berikan butiran penuh, contohnya
jenis ujian yang dilakukan, keputusan dan tarikh.

[ ]No/Tidak [ ] Yes/Ya;

Name of test/Jenis ujian Date/Tarikh Result/Keputusan

_____________________ __________ _______________

_____________________ __________ _______________

_____________________ __________ _______________

[ 60301006 ]
Please provide copy of the results on test done/Sila berikan salinan keputusan ujian yang diberikan.

5. What was the cause of the backache?/Apakah punca/sebab anda mengalami sakit belakang?
[ ] Muscle pain/sakit otot [ ] Osteoporosis / Osteoporosis
[ ] Prolapsed disc/ ceper tergelincir [ ] Paget’s disease of the bone / Penyakit tulang paget
[ ] Scoliosis/ skoliosis [ ] Others/ Lain-lain : ____________

6. How has the backache been treated?/Bagaimanakah keadaan sakit belakang anda dirawat?
[ ] Bed rest/Rehat [ ] Pain killer/Ubat sakit
[ ] Surgery/ pembedahan [ ] Injection/Suntikan
[ ] Massage or ointment / application/urut [ ] Physiotheraphy/ rawatan Fisioterapi
[ ] Others / Lain-lain: _____________________

Date of treatment/Tarikh rawatan : _______/_____/___

7. Have you been advised to undergo any surgery or has any surgery been done? If so, please give
details.Adakah anda pernah dinasihatkan untuk menjalani pembedahan atau adakah pembedahan telah dilakukan? Jika ada,
sila berikan butiran penuh.
[ ]No/Tidak [ ] Yes/Ya;

Type of surgery/Jenis pembedahan Date/Tarikh Hospital/Hospital

___________________________ __________ ______________

___________________________ __________ ______________

I was advised to undergo surgery but no surgery was done/Saya telah dinasihatkan untuk menjalani pembedahan tetapi tidak
dijalankan.

Reason/Sebab : __________________________________________________________________

8. Any follow-up done and date of last follow-up?/Adakah rawatan susulan dijalankan dan tarikh rawatan susulan yang terakhir.
[ ] No/Tidak [ ] Yes/Ya;

(a) Date of last follow up/Tarikh rawatan susulan terakhir : ________________

(b) Name & address of doctor/Nama & alamat doctor : _______________

9. Have you taken time off in the last 2 years due to backache? If so, please state when and duration.
Pernahkah anda mengambil cuti dalam tempoh 2 tahun yang lepas kerana sakit belakang?Jika ada, sila nyatakan bila dan
tempohnya.
[ ]No/Tidak [ ]Yes/Ya;

Year/Tahun Number of days/Jumlah hari

__________ ______________

__________ ______________

10. Are your activities restricted in any way?/Adakah ia menghadkan sebarang aktiviti anda?
[ ] No/Tidak [ ] Yes/Ya;

How?/Bagaimana? : ______________________________________________
11. Has any future treatment been discussed or contemplated such as changes in medication, surgery or other therapy? / Adakah
rawatan yang akan datang dibincangkan/ dipertimbangkan seperti perubahan ubatan, pembedahan atau terapi lain?
[ ] No/Tidak [ ] Yes/ Ya

If Yes, please provide details. / Jika Ya, sila berikan keterangan.

[ ] Surgery/ pembedahan
[ ] Physiotheraphy/ terapi fisio
[ ] Medication / Ubatan
[ ] Others / Lain-lain: _____________________

____________________________________________________________________________________________________________
Declaration / Pengakuan:

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 / certificate. I agree that this form will constitute part of my proposal / certificate 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 / sijil takaful ini. Saya bersetuju bahawa borang ini
akan menjadi sebahagian dari borang cadangan / sijil untuk Takaful Keluarga dan kegagalan untuk mendedahkan sebarang maklumat penting
yang saya ketahui berkemungkinan membatalkan kontrak takaful tersebut.

Signature of applicant / Tandatangan pemohon: Date/Tarikh:

_______________________________ __________