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    Digestive Questionnaire (Medical)

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    Mexico English
    This document is a digestive/bowel disorder questionnaire for a life insurance application. It collects information about the applicant's condition(s), date of diagnosis, any related surgeries or medications, time missed from work/school, and their treating doctor's contact information. The applicant must sign declaring the answers are true and complete.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Digestive Questionnaire (Medical)

    Uploaded by

    Mexico English
    35 views1 page
    This document is a digestive/bowel disorder questionnaire for a life insurance application. It collects information about the applicant's condition(s), date of diagnosis, any related surgeries or medications, time missed from work/school, and their treating doctor's contact information. The applicant must sign declaring the answers are true and complete.

    Original Title

    Digestive_Questionnaire(Medical)

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    This document is a digestive/bowel disorder questionnaire for a life insurance application. It collects information about the applicant's condition(s), date of diagnosis, any related surgeries or medications, time missed from work/school, and their treating doctor's contact information. The applicant must sign declaring the answers are true and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    35 views1 page

    Digestive Questionnaire (Medical)

    Uploaded by

    Mexico English
    This document is a digestive/bowel disorder questionnaire for a life insurance application. It collects information about the applicant's condition(s), date of diagnosis, any related surgeries or medications, time missed from work/school, and their treating doctor's contact information. The applicant must sign declaring the answers are true and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    DIGESTIVE/BOWEL DISORDER QUESTIONNAIRE

    Name: Contract no:

    1. Specific condition(s):

    Gallbladder Ulcer
    Gastroenteritis/gastritis Crohn’s disease
    Hiatus hernia Gallstones
    Irritable bowel Proctitis/Ulcerative Colitis
    Bowel osbstruction Hemorrhoids
    Blood in stool Pancreatitis

    Other ____________________________________________________________________

    2. When was the condition diagnosed? ______________________________________________

    3. Have you had surgery? No Yes

    If “Yes”, when? ______________________________________________________________

    4. Was medication prescribed? No Yes

    From To
    Medication(s) (mm/yyyy) (mm/yyyy)

    5. In the last 12 months or since surgery, have you missed more than 5 days of work/school because
    of the above condition(s): No Yes

    6. Name and address of the doctor with complete records:

    __________________________________________________________

    __________________________________________________________

    __________________________________________________________ Date last seen: _____________________

    I declare that the answers to the above questions are true and complete and shall form part of an Application with Reliance Life
    Insurance for insurance on my life.

    ______________________________________________________ _______________________________________________
    Date _______
    Signature of Life Insured

    th
    UW /Digestive Disorder Qtre /Ver .1.4/28 Dec 2010

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