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Diabetes Questionnaire PDF
Diabetes Questionnaire PDF
Diabetes Questionnaire PDF
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.
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?
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)
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