Supplementary Questions concerning Diabetes (or suspected Diabetes)

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.
1) General Information
Name (Last, First, Middle)
Policy No.
Client No.
New Business Office
Height
ft.
lbs.
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)

MonthDayYear
Date
Weight at time of diagnosis?
lbs.
Details of positive answers
b.) Did you have symptoms leading to diagnosis?
diagnosis?
Details of positive answers
2. Management:

Do you:
a) Have regular medical supervision?
Indicate frequency and date of last consultation
b) Have regular blood sugar estimations?
Indicate dates and results of last two.
c) Have special diet?
Indicate type including amount of carbohydrate, protein, and fat.
d) Take oral diabetic agents?
Indicate name, dosage, and length of time.
e) Have urine checks for sugar regularly?
Indicate results, frequency of testing and date of last.
3. Insulin (Complete only if on insulin)
a) Type, dosage, length of time taken and any change in dosage?
Indicate the information required (type, dosage, length of time taken, and any change in dosage).
b) Have you had insulin reactions?
If so, state the frequency, severity, dates, and reasons.
c) Have you had any lapses of control producing coma, pre-coma, or highly evevated sugars?
Information:
4. Miscellaneous
a) Have you had eye trouble, heart trouble, high blood pressure, albumin in the urine or pain in legs or walking?
Information:
b) Have you had an electrocardiogram exercise test or other special study?
If so, by whom, dates, and results
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 (no., street, municipality)
City
Province
Country
Zip Code
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 (no., street, municipality)
City
Province
Country
Zip Code
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.
You hereby agree that this forms part of your application for insurance on your life.
Place of Signing
Date of Signing (day/month/year)

MonthDayYear
Date
Person being insured if age is 16 & over
Printed Name
Parent if proposed insured is below 18 years old.
Should be Empty:

Supplementary Questions concerning Diabetes (or suspected Diabetes)

1) General Information

2) Questions

3. Your Physician's Information

4. Signatures