Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy/Application Number
1. When were you first diagnosed with raised blood pressure
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
2. Do you know what your blood pressure was at that time? If yes, please provide details:
No
Yes
3. When did you last have your blood pressure measured?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
4. Do you know what your blood pressure was on this occasion? If yes, please provide details:
No
Yes
5. Do you currently take any medication to lower your blood pressure?
Yes
No
If yes, please provide details including names, dosages and frequency:
Rows
Name of Medication
Dose
Frequency
When did you start taking this?
1
2
3
6. Other tan already stated above, have you ever taken any other medication to lower you blood pressure?
Yes
No
If yes, please provide details:
Rows
Name of Medication
Dose
Frequency
When did you start taking this?
1
2
3
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:
Rows
Name of test or investigation
Location
Date
Results
1
2
3
8. Do you suffer from any related problems e.g. raised cholesterol, diabetes mellitus, heart, kidney or eye problems?
No
Yes
9. Other than regular monitoring of your blood pressure, has any future treatment or investigation been discussed or contemplated? If Yes, please provide details:
No
Yes
10. Please provide the name and address of the doctors and/or specialists you have seen in relation to your raised blood pressure.
Rows
Name of doctor, hospital or clinic
Address
Date of last consult
1
2
3
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.
I agree that this form will constitute part of my application for insurance(s) and that failure to disclose any material fact known to me may invalidate my insurance(s).
Name
Signature
Date
.
Month
.
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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