Professional Documents
Culture Documents
Diabetes Questionnaire
Diabetes Questionnaire
9) Have you been hospitalized for control of high blood sugar? Yes No
If Yes, please provide details including dates (month/year).
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10) Since your treatment began, have you ever been hospitalized for diabetic coma or any condition
related to diabetes? Yes No
If Yes, please provide dates and also submit copies of hospitalization records of the episode(s).
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I hereby declare and agree that the above particulars and answers are complete and true, and this
questionnaire will form part of the contract of the desired insurance of my life. I hereby irrevocably
authorize any organization, institution or individual that has any record or knowledge of my/the insured’s
health and medical history to disclose such information or provide such medical records to Tata AIA.
VERNACULAR DECLARATION:
In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.
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Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature