SANLAM LIFE NIGERIA HEALTH DECLARATION FORM

Janet Tugol Proposal No: 801804

Address: Near Ecwa Church Ikkukumug, tudun wada ,jos,
plateau.

1. Have you suffered from any serious personal accident involving fractured skull and NO
bones or unconsciousness or other injury?
2. Have you ever suffered from epilepsy or other mental disturbances? NO

3. Have you been treated for Tuberculosis, Asthma, Pneumonia or any other chest NO
related diseases?
4. Have you experienced recurrent or persistent fever or skin disorder? NO

5. Have you ever been diagnosed of any kidney, liver, vital internal organs infection or NO
blood in urine?
6. Have you ever been diagnosed or suffered from any cancer, cancer-related disease, NO
tumour, any other terminal illness disease?
7. Have you ever been diagnosed or suffered from heart disease, high blood pressure, NO
stroke or any cardiovascular related diseases?
8. Have you ever been diagnosed or suffered from blood sugar-related disease, NO
diabetes and/or diabetic related illness?
9. Have you ever had any minor or major organ transplant? NO

10. Have you been diagnosed or suffered from any other ailment or illness not NO
mentioned in 1 - 9 above, if yes, please state the ailment or illness and the date it was
discovered or diagnosed?
11. Do you consume alcohol? If yes, please state your daily consumption in litres? NO

12. Do you consume tobacco? If yes, please state your daily consumption in sticks? NO

Height (in CM) Weight (in KG)

170CM
65KG

Hospital Hospital Address

Doctor Doctor's Phone How Long with Doctor

Signature Date
31 August 2023

HEALTH DECLARATION FORM PAGE 1 OF 1

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