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PWA Health Questionnaire Form

This document is a health questionnaire for members of an organization applying for loans. It asks the applicant if they have been diagnosed, treated, or monitored for various medical conditions within the last 12 months or 5 years. The applicant must check boxes indicating any applicable conditions. They then must sign a declaration that their answers are true and authorize the sharing of medical information, and provide their printed name, signature and date. The questionnaire aims to obtain relevant health information from loan applicants.

Uploaded by

Kristine Joy Yao
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447 views1 page

PWA Health Questionnaire Form

This document is a health questionnaire for members of an organization applying for loans. It asks the applicant if they have been diagnosed, treated, or monitored for various medical conditions within the last 12 months or 5 years. The applicant must check boxes indicating any applicable conditions. They then must sign a declaration that their answers are true and authorize the sharing of medical information, and provide their printed name, signature and date. The questionnaire aims to obtain relevant health information from loan applicants.

Uploaded by

Kristine Joy Yao
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Health Questionnaire: A questionnaire designed for PWA members-borrowers to identify pre-existing medical conditions over the last 12 months.

HEALTH QUESTIONNAIRE TO BE FILLED-UP BY PWA MEMBERS-BORROWERS

(To be attached to the Loan Application Form)


Have you been diagnosed, treated, medicated, and/or monitored for any of the
conditions listed in the table below within the time frame specified?
O Yes If YES, fill in the square/box next to the condition you have (or had) only if the
applicable time frame applies to you.
O No If NO, continue on the next section

Fill-in for each condition you


For which conditions have you been diagnosed, treated, medicated, have (or had)
and/or monitored? In the last In the last 5
12 months years
1 Chronic Obstructive Pulmonary
2 Cerebro-Vascular Accident or Cardio-Vascular Diseases
3 Neuro-Surgical Conditions or Neurological Diseases
4 Blood Dyscracias
5 Cirrhosis of the Liver
6 Poliomyelitis
7 Autoimmune/Collagen Diseases (Systemic Lupus Erythematosus)
8 Meningities
9 Cancer
10 Encephalitis
11 Bodily injuries caused by violent accidental external and visible
means
12 Chronic Renal Diseases
13 Others (Specify)

I declare that the statements and answers contained herein are full, complete and true, and if
found otherwise, I agree that condonation in case of death or permanent/total incapacity or
disablement may not be granted to me. I hereby authorize any person or entity having a record or
knowledge of my health to give to PWA all information relative to any hospitalization, medical
treatment or consultation that I may have undergone.

Please print name, then sign and date in the space provided.
First Name M.I. Last Name

____________________________________
Signature Date Signed

THANK YOU FOR COMPLETING THE PWA HEALTH QUESTIONNAIRE

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