HEALTH STATEMENT FORM Print / Save as PDF Reset Form HEALTH STATEMENT FORM (MEDICAL QUESTIONNAIRE) NAME : ADDRESS : DATE OF BIRTH : PLACE OF BIRTH : OCCUPATION : LOAN AMOUNT : CONTACT NO. : I hereby declare and agree that all the statements and answers contained herein are true, complete and correct to the best of my knowledge and belief and shall form part of my application for MRI insurance. It is understood and agreed that no MRI insurance coverage shall be effected unless and until this application is approved and the full premium is paid during my continued good health. 1. Do you have or did you have any of the following during the past 5 years? CHECK APPROPRIATE BOX. If YES, give details (can use back page): Yes No a. Consulted or been treated by any Physician or other Medical Practitioner for any disease pertaining to (1) brain or nervous system? (2) lungs or respiratory tract? (3) heart or blood vessels? (4) stomach or any abdominal organ? (5) AIDS, AIDS-related complex or AIDS-related conditions? (6) Any form of cancer? b. Tested positive for antibodies to the AIDS virus? c. Any accident, injury, surgical operation, hospital confinement, medical advice or examination other than those mentioned above? d. Dizzy spells; recurrent chest, back, or abdominal pain; persistent cough; blood in the urine; blood spitting? e. Any lump or growth in any part of the body or any other physical deformity or abnormality, as impaired hearing or eyesight, lameness, or amputation? f. X-ray, electrocardiogram (ECG), blood analysis, or other diagnostic tests? 2. For FEMALE ONLY: Are you now pregnant? YES If pregnant, state how many months: months. NO 3. Present HEIGHT and WEIGHT: ft/in lbs Lost weight in the last 12 months? If so, how much and why? YES NO 4. Are you to the best of your knowledge in good health and free from any physical deformity? YES NO If NO, give details: ✓ SIGNATURE OVER PRINTED NAME OF THE PROPOSED INSURED / DEBTOR AUTHORIZATION TO FURNISH MEDICAL INFORMATION I authorize any physician, hospital, clinic, insurance company, or other organization, entity, institution, or person that has any records or knowledge of me, to give Lockton Philippines Insurance and Reinsurance Brokers, Inc. or its representative any information with reference to health, hospitalization, consultation, advice, examination, treatment, disease, or ailment. A photostatic copy of this authorization shall be as effective and as valid as the original. This authorization is in connection with my application for MRI insurance only. Done at this day of 20 ✓ SIGNATURE OVER PRINTED NAME OF THE PROPOSED INSURED / DEBTOR ✓ WITNESS (PRINT NAME & SIGN ABOVE)
