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Diabetes Questionnaire PDF

This 3-sentence summary provides an overview of the key details from the supplementary diabetes questionnaire: The questionnaire collects information about an applicant's diabetes diagnosis and management, including date of diagnosis, symptoms, treatment, medication, diet, test results, complications, and physician details. It seeks to determine if the applicant has regular medical supervision and blood sugar monitoring, adheres to dietary and medication guidelines, and has experienced any issues related to insulin, blood sugar control, or common diabetes complications. The final section requires signatures from the applicant and parent to verify the information provided.

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Lourdes Erika Cruz
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233 views2 pages

Diabetes Questionnaire PDF

This 3-sentence summary provides an overview of the key details from the supplementary diabetes questionnaire: The questionnaire collects information about an applicant's diabetes diagnosis and management, including date of diagnosis, symptoms, treatment, medication, diet, test results, complications, and physician details. It seeks to determine if the applicant has regular medical supervision and blood sugar monitoring, adheres to dietary and medication guidelines, and has experienced any issues related to insulin, blood sugar control, or common diabetes complications. The final section requires signatures from the applicant and parent to verify the information provided.

Uploaded by

Lourdes Erika Cruz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Supplementary Questions concerning

Diabetes (or suspected Diabetes)


Please PRINT clearly. In this form, you and your refer to the person being insured, while we, us, our and the Company refer to
Use BLACK ink. Sun Life of Canada (Philippines), Inc., a member of the Sun Life Financial group of companies.

1 General Information
Name (Last, First, Middle)
SARAJAN JR, EUSEBIO ARADOR
Policy No. Client No. New Business Office
0827381069 3006151169 HYPERION TREE
Height Weight 1 year ago Current weight
ft. in. lbs. lbs.

2 Questions
The person being insured must answer the following questions. Please indicate details for each question on the space provided.

1. Diagnosis Details of positive answers


a) Date diabetes diagnosed?
Date (day/month/year)

Weight at time of diagnosis?


Weight:
lbs.

b) Did you have symptoms leading to


diagnosis? Yes No
Thirst

Increased frequency of urination


at night (more than 3x)

Weight loss

2. Management: Do you:
a) Have regular medical supervision? Yes No
(indicate frequency and date of last
consultation)
b) Have regular blood sugar estimations? Yes No
(dates and results of last two)
c) Have special diet? Yes No
(indicate type including amount of
carbohydrate, protein and fat)
d) Take oral diabetic agents? Yes No
(indicate name, dosage, length of time)
e) Have urine checks for sugar regularly? Yes No
(indicate results, frequency of testing
and date of last)
3. Insulin (Complete only if on insulin)
a) Type, dosage, length of time taken and
any change in dosage? Yes No
b) Have you had insulin reactions? Yes No
(If so, state frequency, severity, dates,
reasons)
c) Have you had any lapses of control Yes No
producing coma, pre-coma, or highly
elevated sugars?

PlPlease submit in 2 copies


0DIAQ-2-06
*0DIAQ-2-06*
0DIAQ-2-06 0827381069I14121973
2 Questions (continued)

4. Miscellaneous
a) Have you had eye trouble, heart trouble, Yes No
high blood pressure, albumin in the urine
or pain in legs or walking?
b) Have you had an electrocardiogram Yes No
exercise test or other special study?
(If so, by whom, dates, results)

c) Indicate your alcohol consumption


as accurately as possible

3 Your Physician’s Information

Information about your regular attending physician


Please provide name and Name of regular attending physician (First Name, Last Name)
address of your
attending physician and Address (no., street, municipality)
the doctor following the
diabetes. City Province Country Zip Code

Home Phone Business Phone Cell Phone E-Mail Address

Information about the doctor following the diabetes


Name (First Name, Last Name)

Address (no., street, municipality)

City Province Country Zip Code

Home Phone Business Phone Cell Phone E-Mail Address

4 Signatures

This section must be You hereby agree that this forms part of your application for insurance on your life.
signed by the person Place of Signing Date of Signing (day/month/year)
being insured and, the
parent, if applicable.
Signature of person being insured if age is 16 & over Printed Name
X
Signature of parent if proposed insured is below 18 years old Printed Name
X

0DIAQ-2-06 PlPlease submit in 2 copies

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