Professional Documents
Culture Documents
1) Which form of arthritis do you suffer from? E.g. Rheumatoid arthritis, osteoarthritis, etc
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3) How would you describe the current condition? ( mild/ moderate/ severe)
(Improving/ progressively / worsening)
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4) a) What is the current extent of symptoms? Please specify the joints where you get the Maximum
symptoms.
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(b) Are your activities restricted in any way? If Yes, please provide details.
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(c)Do you use a walking stick or other mobility aids? If Yes, please provide details.
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(d)What treatment has or is currently being prescribed for this condition?
Please state name/type and dosage.
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(e) Are you taking corticosteroids for the condition?
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5) a)Have you been advised to have, or have you had a joint replacement or any other surgery or
intervention? If yes, please state details.
Yes No If Yes, please provide details
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6) Which investigations were done? ( Eg, X –rays, MRI scans, CT scan, blood tests, Full medical
exam, other etc). Please provide copy of medicals report accordingly.
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I hereby declare and agree that the above particulars and answers are complete and true, and this
questionnaire will form part of the contract of the desired insurance of my life. I hereby irrevocably
authorize any organization, institution or individual that has any record or knowledge of my/the insured’s
health and medical history to disclose such information or provide such medical records to Tata AIA.
VERNACULAR DECLARATION:
In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.
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Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature