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    AXA Hypertension Questionnaire

    Uploaded by

    Claudine Limasa Tabudlong
    This document is a hypertension questionnaire for an insurance applicant. It collects details about the applicant's hypertension diagnosis and treatment history, including when it was diagnosed, recent blood pressure readings, current medications, hospitalizations, and recommended tests or follow-ups. The applicant is asked to provide their attending physician's details and declares that their answers are true and complete.

    Copyright:

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

    AXA Hypertension Questionnaire

    Uploaded by

    Claudine Limasa Tabudlong
    38 views2 pages
    This document is a hypertension questionnaire for an insurance applicant. It collects details about the applicant's hypertension diagnosis and treatment history, including when it was diagnosed, recent blood pressure readings, current medications, hospitalizations, and recommended tests or follow-ups. The applicant is asked to provide their attending physician's details and declares that their answers are true and complete.

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    AXA hypertension questionnaire

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    This document is a hypertension questionnaire for an insurance applicant. It collects details about the applicant's hypertension diagnosis and treatment history, including when it was diagnosed, recent blood pressure readings, current medications, hospitalizations, and recommended tests or follow-ups. The applicant is asked to provide their attending physician's details and declares that their answers are true and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    38 views2 pages

    AXA Hypertension Questionnaire

    Uploaded by

    Claudine Limasa Tabudlong
    This document is a hypertension questionnaire for an insurance applicant. It collects details about the applicant's hypertension diagnosis and treatment history, including when it was diagnosed, recent blood pressure readings, current medications, hospitalizations, and recommended tests or follow-ups. The applicant is asked to provide their attending physician's details and declares that their answers are true and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Policy Number/s

    HYPERTENSION QUESTIONNAIRE - APPLICANT


    (To form part of the policy contract)

    Name of Applicant:

    1. When was your hypertension first diagnosed?


    2. What was your most recent blood pressure reading within the last 6 months?

    3. Are you currently on medication for hypertension?


    YES, please provide details in below table and answer to question 3.1
    NO, please provide reason(s) why you are not currently on medication for your hypertension:

    Frequency Date Medication


    Name of Drug Date Medication Stopped & Reason/s
    and Dosage Started

    3.1 Has your medication for hypertension been increased by your attending physician in
    the past 6 months? YES If yes, please provide details NO

    4. Have you been hospitalized or had emergency care due to your hypertension in the past 3 years?
    YES NO
    If yes, please provide details (e.g. date of confinement, treatment received, name of hospital, etc.)

    5. Other than for the purpose of regular check-ups, has any further treatment, investigation or follow-up
    been discussed, recommended, or otherwise contemplated in relation to this condition?
    YES, please provide details below NO

    Date Type of Diagnostic Test Results


    / / ECG
    / / Chest x-ray
    / / Treadmill Stress Test
    / / 2D Echo
    / / 24-Hour Holter Monitoring
    / / Urinalysis
    / / Others:
    Form No. UW (A) - 2019-013 1 of 2
    6. Have you ever had or do you currently have any of the following? YES, please specify NO
    Eye Disease Proteinuria Stroke

    7. Please provide details of your attending physician.

    Name of Attending Physician:


    Specialization:
    Contact Number:
    Clinic Address:
    Email Address:

    DECLARATION
    I confirm that the answers I have given are, to the best of my knowledge, true and correct and that
    I have not withheld any material information that may influence the assessment or acceptance of
    this application.

    I understand that the personal information collected or held by AXA Philippines may be used,
    stored, transferred (whether within or outside the Philippines) to such persons as AXA Philippines
    may consider necessary, including any of its affiliates or related companies, or any
    individuals/organizations/corporations/entities associated with AXA Philippines to process and
    deal with my application/policy to which this is appended to.

    I agree that this form will constitute part of my application for insurance and that failure to disclose
    any material fact known to me may invalidate my insurance. Furthermore, I understand that
    declaration of any untruthful statement may also be a ground to invalidate my insurance.

    Name and Signature Date of Signing

    AXA PHILIPPINES
    34F GT TOWER INTERNATIONAL
    6813 Ayala Avenue corner H.V. Dela Costa St. | Makati City 1226, Philippines

    Form No. UW (A) - 2019-013 2 of 2

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