Blood Pressure Questionnaire
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Policy/Application Number
1. When were you first diagnosed with raised blood pressure?
If yes, please provide details
2. Do you know what was your blood pressure at that time?
Yes
No
3. When did you last have your blood pressure measured?
4. Do you know what was your blood pressure on this occasion?
Yes
No
If yes, please provide details
5. Do you currently take any medication to lower your blood pressure?
Yes
No
If yes, please provide details:
6. Other than already stated above, have you ever taken any other medication to lower your blood pressure?
Yes
No
If yes, please provide details:
7. Have you ever had any related tests or investigations e.g. blood test, 24 hour blood pressure recording , electrocardiograph, echocardiograph, urine test etc.?
Yes
No
If yes, please provide details:
8. Do you suffer from any related problems e.g. raised cholesterol, diabetes mellitus, heart, kidney or eye problems?
Yes
No
If yes, please provide details:
9. Other than regular monitoring of your blood pressure, has any future treatment or investigation been discussed or contemplated?
Yes
No
If yes, please provide details:
10. Please provide the name and address of the doctors and/or specialists you have seen in relation to your raised blood pressure.
11. Please provide any additional information that you feel is important
Declaration
I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld any material information that may influence the assessment or acceptance of this application.
Name
Preview PDF
Submit
Should be Empty: