Hypertension Questionnaire

This questionnaire should be completed by the medical attendant.

Full name of the person to be assured:

Date of birth:
Patient since:

Please answer each question and where appropriate provide particulars.

1. How long have you attended the
patient?

2. When did you first discover the

patient's blood pressure was
above normal?

3. What were the blood pressure

readings at that time? (Please
give highest and lowest pre-treatment
figures)

4. Were any fundoscopic abnormalities

or other complications of hypertension
noted? If YES, please provide details

5. When was anti-hypertensive treatment

started?

What type of treatment was given?

(e.g. diet, drugs, or combination)

If drugs were prescribed, give

details including dosage. (If
different drugs were used at
different periods, please indicate
these particulars for each period
and state reason for change.

Island Life Assurance Co. Ltd June 2012

 6. What effect did treatment have
on the blood pressure? Please
give representative readings

Is the patient still on treatment?

If NO, when was the treatment
stopped?

7. What are the applicant's most

recent blood pressure levels?

8. Please give dates and results

of any electrocardiographic,
radiological or other investigations
which may have been carried out

____________________________________________

Date, signature and stamp of medical attendant

Island Life Assurance Co. Ltd June 2012