NTUC Income Insurance Co-operative Limited

NTUC Income Centre 75 Bras Basah Road Singapore 189557 | t. 63 INCOME (6346 2663) | f. 6338 1500 | csquery@income.com.sg | www.income.com.sg
GASTRITIS QUESTIONNAIRE
Particulars of Proposer / Insured
Name (as shown in NRIC) Proposal No.
NRIC/Passport No. Occupation/Position Height (m) Weight (kg)
Questions
1. When were you frst diagnosed with dyspepsia? (i.e. pain or discomfort over the upper part of the stomach)
2. When did you last experience this gastric discomfort?
3. How often do you have gastritis? (E.g. how many times in the last 12 months)
4. How long do you take to recover from each attack?
5. What type of medications were you prescribed? Please provide names of medication (E.g. Omeprazole, Lansoprazole, Famotidine, Mylanta, Mucaine, etc)
and dosage.
6. What are the probable causes of gastritis? (E.g. stress, food, indigestion, etc)
7. Were the symptoms mild or severe?
8. Were they accompanied by acute pain or frequent vomitting?
9. Have there been any signs or symptoms of peptic ulcer disease, such as pain when hungry and relieved by food, passing blood in stool (maelena) or vomited blood?
10. Did you undergo any investigation such as OGD (gastroscopy), barium studies, ultrasound, CAT scan, MRI? If Yes, please provide details of investigations
and results.
11. Have you ever been hospitalised for gastritis? If Yes, please provide date of admission, treatment and hospital.
12. If you are still on treatment and follow up, please provide date of last review consultation and the next review appointment.
13. Please provide name and address of doctor and clinic you currently seeing.
Declaration By The Proposer
I hereby declare that the foregoing answers are true and whether written by me or anyone on my behalf I accept full responsibility for them. I also agree that the questions and answers
above shall form part of the proposal for life insurance and shall be the basis of the contract between me and NTUC Income.

Signature of Proposer Date (dd/mm/yyyy)
LI/QN/09/2009