CARDIOLOGY MEDICAL QUESTIONNAIRE

CARDIOLOGY MEDICAL QUESTIONNAIRE
YOUR MEDICAL CONDITION
1. Have you ever had symptoms or been diagnosed with any type of heart disorder or cardiovascular disease?

YesNo

Please let us know which policyholder(s) are affected

	Lead policyholder	Additional Policyholder(s)
Angina
Heart attack
Cardiomyopathy
Coronary Artery Disease
Heart infections
Arrhythmia / abnormal heart rhythms or pulse

We require further information about your condition. Please complete our full cardiology questionnaire and return it to enquiries@healthcareinternational.com
Should be Empty: