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HYPERTENSION QUESTIONNAIRE

Name of Applicant: Reference No.:


Elviza G. Amora 1019874604

1. When was your hypertension (elevated blood pressure / high blood pressure) first found?
Date: (MM/DD/YYYY) 5/4/2013 Blood Pressure Reading: 200/110

2. Please provide full name and address of your regular doctor for hypertension and date(s) of
consultation in last 12 months.
Name of Doctor: Dr. Luisa Bisnar
Address: Davao Medical Foundation Hospital, Davao City
Date: (MM/DD/YYYY) 5/4/2013
3. Is/ Are there any other doctor that you also consult in relation to hypertension? [ ] Yes [ ] No
X
If YES, please provide full name and address and date of consultation in last 12 months.
Name of Doctor:
Address:
Date: (MM/DD/YYYY)
4. Please give your last 3 blood pressure readings.
Date: (MM/DD/YYYY) Blood Pressure Reading:

5. Has any of the following medical test been performed for purposed of your hypertension in last 12
months?
[ ] Blood cholesterol / lipid test
[ ] ECG (including both resting and stress ECG)
[ ] Echocardiogram
[ ] Urine test or renal function test
[ ] Others (Please specify)
[X] No test
Please also provide the medical report copy.

6. Do you suffer from any of the following diseases? [ ] Yes [X] No


If YES, please tick if appropriate.
[ ] Kidney disorder / abnormalities in urine (e.g. blood, protein, glucose, etc)
[ ] Heart, brain or circulatory disorder
[ ] High cholesterol
[ ] Eye disorder
If any of above is ticked, please provide full details including the attending doctor full name and
address.

7. Have you been told that the hypertension is secondary to other reasons e.g. diabetes, heart disease
and kidney disease? [ ] Yes [ X] No
If YES, please provide details.

I hereby declare and agree that the above particulars and answers are true, complete and correct. I also
understand that the Company believes them to be such, will rely and act on them, otherwise policy issued
hereunder may be void. The information provided by me together with the relevant policy issued
shall constitute the entire contract between myself and the Company.
Helemina C.
Guanzon/007304639 June 29, 2017
Signature of Applicant Soliciting Agent/Code No. Date

QR-UND-HPNQ / REVISION 1 / JULY 2012 PHILAM LIFE CUSTOMER CONFIDENTIAL