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  • Kidney Disease Questionnaire For Proposed Insured/Owner

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    Sincerely Reyn
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    This document is a kidney disease questionnaire for a proposed insured or policy owner. It collects personal information and details about the individual's kidney disease diagnosis and treatment history. The questionnaire asks when kidney disease was diagnosed, whether the individual has been hospitalized for it, current medications, other existing medical conditions, a family history of kidney disease, and any absences from work or school due to the condition. The individual affirms that their answers are true and grants permission for the insurer to obtain related medical information if needed.

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    Kidney-Disease-Questionnaire

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    This document is a kidney disease questionnaire for a proposed insured or policy owner. It collects personal information and details about the individual's kidney disease diagnosis and treatment history. The questionnaire asks when kidney disease was diagnosed, whether the individual has been hospitalized for it, current medications, other existing medical conditions, a family history of kidney disease, and any absences from work or school due to the condition. The individual affirms that their answers are true and grants permission for the insurer to obtain related medical information if needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    81 views1 page

    Kidney Disease Questionnaire For Proposed Insured/Owner

    Uploaded by

    Sincerely Reyn
    This document is a kidney disease questionnaire for a proposed insured or policy owner. It collects personal information and details about the individual's kidney disease diagnosis and treatment history. The questionnaire asks when kidney disease was diagnosed, whether the individual has been hospitalized for it, current medications, other existing medical conditions, a family history of kidney disease, and any absences from work or school due to the condition. The individual affirms that their answers are true and grants permission for the insurer to obtain related medical information if needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    Kidney Disease Questionnaire for Proposed Insured/Owner

    Policy Number
    Please fill in block letters & tick appropriate boxes and circles.
    A. Personal Information of Proposed Insured / Owner
    Last Name First Name Ext Name Middle Name

    m m d d y y y y
    Date of Birth: / /

    B. Kidney Disease Questionnaire


    1.) When was the diagnosis of Kidney disease made?
    m m d d y y y y
    Date of Diagnosis: / /

    Name of Attending Physician/s: _______________________ Specialty of Attending Physician: ___________________

    Clinic Address : ____________________________________ Clinic Hours : _____________________________________

    Contact number : ____________________________________

    2.) Have you ever been confined because of kidney disease? Yes No If Yes, provide details below.
    m m d d y y y y m m d d y y y y
    Date of Admission: / / Date of Discharge: / /

    Name of Medical Institution:

    Address : _______________________________________________ Contact number:

    Name of Attending Physician/s :

    3.) What are your medications?


    Name of Drug Dosage Date Started
    (include preparation) m m d d y y y y
    / /
    / /
    / /

    4.) Do you have any other existing medical condition or disease? Yes No
    If yes, provide details.

    5.) Is there anyone else in the family who has kidney disease? Yes No
    If yes, provide degree of relationship.

    6.) Have you ever been absent or off from school or work due to kidney disease? Yes No
    If yes, provide details below:
    m m d d y y y y
    Number of times in a year: Date of last occurrence: / /

    C. Affirmation Section
    I hereby declare that the answers/statements that I have made to this questio nnaire are true and accurate representatio ns o f my health co nditio n. Sho uld FWD need additio nal info rmatio n,
    I hereby autho rized the abo ve mentio ned physician, surgeo n, o r medical institutio n to pro vide FWD o r its autho rized representative, the M edical Info rmatio n B ureau o r any go vernment
    agency requiring such with info rmatio n o r do cuments pertaining to my health co nditio n. Further, I am fully aware that statements made to this questio nnaire shall fo rm part o f and be the
    basis fo r the issuance o f the po licy bearing the same number as stated abo ve.

    m m d d y y y y
    Place Signed Date: / /

    Signature over Printed Name of Proposed Insured / Owner

    KIDQV206112014

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