Supplementary Questions concerning Chest Pain or Discomfort

Supplementary Questions concerning Chest Pain or Discomfort
Please PRINT clearly. Use BLACK ink.

In this form, you and your refer to the person being insured, while we, us, our and the Company refer to Sun Life of Canada (Philippines), Inc., a member of the Sun Life Financial group of companies.
1. General Information
Name

First NameMiddle NameLast Name
Policy No.
Client No.
New Business Office
2. Questions

The person being insured must answer the following questions. Please indicate details for each question on the space provided.
1) Frequency of episodes of discomfort with appropriate dates
You have had only one episode of chest discomfort.
Date (day/month/year)

DayMonthYear
Date
b) You have had ______ of episodes.

Other
Date (day/month/year)

DayMonthYear
Date
c) If episodes have been of recurring nature. Frequency (indicate number per day, week or month)
Discomfort typically occurs
Last episode occurred. Date (day/month/year)

DayMonthYear
Date
N.B. Questions below are to be answered as related to a single or typical episode
2) a) Describe location of discomfort in relation to the breast-bone, e.g. left of breast-bone, right of breast-bone, directly under breast-bone, in region of the nipple, etc
b) In the accompanying diagram shade in the area corresponding to the location and the extent of the discomfort.
3) For how long did the discomfort last? Indicate number of seconds/ minutes/ hours.
Indicate number of seconds/minutes/hours.

Seconds
Indicate number of seconds/minutes/hours.

Minutes
Indicate number of seconds/minutes/hours.

Hours
4) Describe the character and severity of the discomfort by checking the appropriate descriptive terms.
Other (describe)
4) continuation.
5) State whether pain or discomfort radiated to other regions, e.g., the arms, the neck, the jaw.
6) Was there
6) Continuation
7) a) Was the discomfort relieved promptly by nitroglycerine?
7) a) continuation
7) b) Did you or do you take nitrtoglycerine?
7) b) continuation
c) What did you do/take to relieve the chest pain?
d) Other medications?
8) Did loss of time from work occur on any occasion? If so, when and for how long?
9) Were you informed that the discomfort was due to heart disorder? If not, what was the explanation?
10) Were any tests done?
a) resting ECG
b) exercise ECG
b) other (specify)
10) Continuation
Attending Physician’s Information
Attending Physician's Information

Please provide name and address of your attending physician.
Name of regular attending physician (First Name Last Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone
Format: (000) 000-0000.
Business Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
E-Mail Address
example@example.com
4. Signatures

This section must be signed by the person being insured and, the parent, if applicable.
Place of Signing
Date of Signing (day/month/year)

MonthDayYear
Date
Signature of person being insured if age is 16 & over
Printed Name
Signature of person being insured is below 18 years old
Printed Name
An Online Form by Jojo Porquez.
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Supplementary Questions concerning Chest Pain or Discomfort

1. General Information

2. Questions

N.B. Questions below are to be answered as related to a single or typical episode

Attending Physician's Information

4. Signatures