Paramount Health Services & Insurance TPA Pvt. Ltd.

Questionnaire for Patient

Name of Patient: ____________________________________ Age - _____ / Sex _________________

Name of Insured ____________________________________

Relation with Insured_________________________________

Address______________________________________________________________________________

_______________________________________________________________________________

Hospitalization at _______________________________________________________________________

_______________________________________________________________________________

D.O.A.: ____________ D.O.D. : ______________

Name of Insurance Co: ____________________________________

Policy No. __________________________________
Period of Insurance from: to: _________

Policy Inception Date: ______________________

Policy Purchased – Agent/ Online Agent Name and Contact No.:_______________________

Mode of Payment ______________________ Paid by __________________________________

Educational Qualification ________________________ Email ID: _________________________________

Occupation_____________________________ Monthly Income_______________________________

Employer’s Name_______________________________________________________________________

Address of place of work__________________________________________________________________

_____________________________________________________________________________________

Copy of the Aadhar /Pan Card ____________________________________________________________

Photo ID Proof attached: Voter ID card / Passport copy / Employer’s ID card / Ration card / Driving License /
Any Other (to Specify)

_____________________________________________________________________________________

Signature / Thumb Impression:

Name:

Date
 Paramount Health Services & Insurance TPA Pvt. Ltd.
Questionnaire for Patient

Part A: Family Details:

1. No. of persons in the family: ______

2. No. of persons covered under this insurance policy ______________

3. Details of the policies of other family members, if not covered in present policy –

Name of Persons covered Policy no. Period of insurance Insurer Sum Insured

4. Reasons for not insuring remaining members of the family:

__________________________________________________________________________________

5. Purpose of Buying this policy: Tax Saving / Health Cover / Any other(specify)_____________________

6. Are you covered under any other insurance policy (Life/PA/Health insurance): Yes / No

If Yes, Provide details (Policy Number, Insurance Company’s Name and Period of Cover):

______________________

__________________________________________________________________________________

__________________________________________________________________________________

7. Name and contact details of your family Doctor / or Doctor you consulted in recent Past:

__________________________________________________________________________________

8. Reasons for this visit to your Doctor (complaints / disease Diagnosed and Duration of
Complaints):
__________________________________________________________________________________

__________________________________________________________________________________

Signature / Thumb Impression:

Name:

Date
 Paramount Health Services & Insurance TPA Pvt. Ltd.
Questionnaire for Patient

Part B: Present Hospitalization details:

9. Initial Complaints

Complaints Duration (DD/MM/YYYY)

10. When did you first consult a doctor for your complaints as above:_____________________________

11. Name & Contact details of the Doctor consulted first: ______________________________________

12. Please provide treatment / consultation papers thereof with investigation reports & Cash memos of

Medicines Purchased and expenses incurred: ___________________________________________

13. Details of subsequent consultations with Doctors prior to hospitalization at _____________________

on _________ with name of the Doctor/s & dates of Consultation and details of the treatment /

Medicines prescribed and investigations recommended ___________________________________

________________________________________________________________________________

14. Copies of the Consultation papers, investigation reports, Bills / cash memo of Investigations done &

Medicine purchased as advised by the Doctor/s prior to this hospitalization: Yes / No

15. Did you take any medicines or undergo any test / investigation prior to your hospitalization at

_________________________________________on ______________________: Yes / No

If Yes, Provide details: _______________________________________________________________

Signature / Thumb Impression:

Name:

Date
 Paramount Health Services & Insurance TPA Pvt. Ltd.
Questionnaire for Patient

16. When did you consult Treating Doctor for the first time:_____________________________________

17. Name of the Doctor_________________________________________________________________

18. What was the diagnosis? On what basis? ________________________________________________

19. Copy of the prescription: Yes / No

20. When did you undergo tests like ECG/TMT / ECHO / ECG / Blood Sugar / Lipid Profile/ MRI in past?

Copies of Investigation reports and Doctor’s prescription: ____________________________________

21. Name of the Hospital / Laboratory and copies of the reports:__________________________________

__________________________________________________________________________________

22. Is there any past hospitalization? Kindly provide details and documents for all past hospitalizations?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

23. Do you have history of following?

Ailment Yes / No Duration (DD/MM/YYYY)

Hypertension
Diabetes
Bronchial Asthma
Epilepsy
Accidental Injury
Other
Any Surgery/Operation in past

Signature / Thumb Impression:

Name:

Date
 Paramount Health Services & Insurance TPA Pvt. Ltd.
Questionnaire for Patient

Do you take alcohol? If yes, since when _______ specify quantity ______

24. Did you take any medicines after the discharge from hospital? Yes / No

25. If yes, for how many days? ________ days

26. What was the amount spent by you on these medicines? Rs.______________________________

27. Provide copies of the bills / cash memos:

28. Did you consult the Doctor after the discharge? Yes / No Details_______________________

29. Provide copies of the consultation papers:

30. Time of admission (approx.) ____________ Morning / Afternoon / Evening / Night

31. Time of discharge (approx.) ____________ Morning / Afternoon / Evening / Night

32. What was the final diagnosis said by the doctor?

________________________________________________________________________

33. Details of treatment received

a. I V fluids Yes / No For how many days _______
b. Tablet / Capsule Yes / No For how many days _______
c. Operation / surgery____________________________________________________________

34. What were the investigations done during hospitalization?

a. Blood test Yes / No How many times? ____________________

b. X – Ray Yes / No Of which body part? ____________________
c. Ultra sound Yes / No Of which body part? ____________________
d. C.T. / MRI Yes / No Of which body part? ____________________
e. ECG Yes / No
f. 2D ECHO Yes / No
g. CAG Yes / No
35. How much was the hospital bill? Rs.____________________________________________________
Signature / Thumb Impression:

Name:

Date
 Paramount Health Services & Insurance TPA Pvt. Ltd.
Questionnaire for Patient

36. Mode of Payment? _________________________________________________________________

37. Did you sign the hospital bill at the time of discharge? Yes / No

38. What was the name of your attending Doctor? ____________________________________________

39. Type of the room you stayed in? Single room / Double room / General ward / A.C. room/ Sharing
Floor and Room Number____________________________________________________________

40. Sequence of events:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

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________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Signature / Thumb Impression:

Name:

Date
 Paramount Health Services & Insurance TPA Pvt. Ltd.
Questionnaire for Patient
________________________________________________________________________________________

Declaration:

I hereby declare that I fully understand the meaning & scope of my statement as above and confirm that I have
not been induced by anyone to make such statement. I have been explained the importance of making the
above statement in a language known to me by the verifier.

Signature of the Insured/Patient: __________________ Signature of the Witness:___________________

Name of the Insured/Patient: __________________ Name of the Witness: ______________________

Address of the Insured:__________________ Address of the Witness: ___________________

Relation with Patient:______________________

Contact Details: __________________ Contact Details: _______________________

Date: ________________ Date: ________________

Signature / Thumb Impression:

Name:

Date