Supplementary Questions concerning Diabetes (or suspected Diabetes)

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.
Name (Last, First, Middle)
Policy No.
Client No.
New Business Office
Height ft. in
Weight 1 year ago lbs. Current weight lbs.
2. Questions

The person being insured must answer the following questions. Please indicate details for each question on the space provided.
1. Diagnosis
a) Date diabetes diagnosed?
Date (day/month/year)

DayMonthYear
Date
Weight at time of diagnosis?
lbs
Details of positive answer
b) Did you have symptoms leading to diagnosis?
diagnosis?
Details of positive answer
2. Management: Do you
a) Have regular medical supervision? (indicate frequency and date of last consultation)
Details of positive answer
b) Have regular blood sugar estimations? (dates and results of last two)
Details of positive answer
c) Have special diet? (indicate type including amount of carbohydrate, protein and fat)
Details of positive answer
d) Take oral diabetic agents? (indicate name, dosage, length of time)
Details of positive answer
e) Have urine checks for sugar regularly? (indicate name, dosage, length of time)
Details of positive answer
3. Insulin (Complete only if on insulin)
a)Type, dosage, length of time taken and any change in dosage?
Details of positive answer
b) Have you had insulin reactions? ( If so, state frequency, severity, dates, reasons)
Details of positive answer
c) Have you had any lapses of control producing coma, pre-coma, or highly elevated sugars
Details of positive answer
4. Miscellaneous
a) Have you had eye trouble, heart trouble, high blood pressure, albumin in the urine or pain in legs or walking?
Details of positive answer
b) Have you had an electrocardiogram exercise test or other special study? (If so, by whom, dates, results)
Details of positive answer
c) Indicate your alcohol consumption as accurately as possible
3. Your Physician's Information

Please provide name and address of your attending physician and the doctor following the diabetes.
Information about your regular attending physician
Name of regular attending physician (First Name, Last 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
Information about the doctor following the diabetes
Name (First Name, Last 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)

DayMonthYear
Date
Signature of person being insured if age is 16 & over
Printed Name
Signature of parent if proposed insured is below 18 years old
Printed Name
An Online Form by Jojo Porquez.
Should be Empty:

2. Questions

3. Your Physician's Information

4. Signatures