Asthma Bronchitis Questionnaire V1

Supplementary Questions concerning Asthma, Bronchitis, or other Pulmonary Symptoms
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

Information about the person being insured.
Name (Last, First, Middle)
Policy No.
Client No.
New Business Office
2. Questions

The person being insured must answer the following questions. Please indicate details for each questions on the space provided.
1. Briefly indicate the symptoms you experienced in your last 3 attacks (e.g., cough, sputum production, wheezing respiration, shortness of breath) and the approximate date of onset.
2. Do you have shortness of breath?
If "yes", describe the degree (e.g., occurring on ordinary activity or unaccustomed activity?)
3. a) Do you cough? (a.1. only with colds)
Information:
Do you cough (a.2. in the morning)
Information:
Do you cough (a.3. chronic daily cough)
Information
b) If cough is productive sputum, describe in details (e.g., amount, color, any blood?)
4. a) Do you suffer from attacks of asthma or wheezing?
If yes, how frequent are these attacks?
If yes, when was your last attack?
b) Do the asthma attacks occur year-round or seasonally?
Information:
5. Do you regularly take any treatment of medication?
Information:
6. Have your undergone any special tests (other than routine chest x-rays) to investigate your lung condition?
If "Yes", give details, dates, and results.
7. State the name and address of your doctor and date last consulted.
3. 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
Printed Name
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 Asthma, Bronchitis, or other Pulmonary Symptoms

1. General Information

2. Questions

3. Signatures