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    PWA Health Questionnaire Form

    Uploaded by

    Kristine Joy Yao
    This document is a health questionnaire for members of an organization applying for loans. It asks the applicant if they have been diagnosed, treated, or monitored for various medical conditions within the last 12 months or 5 years. The applicant must check boxes indicating any applicable conditions. They then must sign a declaration that their answers are true and authorize the sharing of medical information, and provide their printed name, signature and date. The questionnaire aims to obtain relevant health information from loan applicants.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    PWA Health Questionnaire Form

    Uploaded by

    Kristine Joy Yao
    100 views1 page
    This document is a health questionnaire for members of an organization applying for loans. It asks the applicant if they have been diagnosed, treated, or monitored for various medical conditions within the last 12 months or 5 years. The applicant must check boxes indicating any applicable conditions. They then must sign a declaration that their answers are true and authorize the sharing of medical information, and provide their printed name, signature and date. The questionnaire aims to obtain relevant health information from loan applicants.

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    This document is a health questionnaire for members of an organization applying for loans. It asks the applicant if they have been diagnosed, treated, or monitored for various medical conditions within the last 12 months or 5 years. The applicant must check boxes indicating any applicable conditions. They then must sign a declaration that their answers are true and authorize the sharing of medical information, and provide their printed name, signature and date. The questionnaire aims to obtain relevant health information from loan applicants.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    100 views1 page

    PWA Health Questionnaire Form

    Uploaded by

    Kristine Joy Yao
    This document is a health questionnaire for members of an organization applying for loans. It asks the applicant if they have been diagnosed, treated, or monitored for various medical conditions within the last 12 months or 5 years. The applicant must check boxes indicating any applicable conditions. They then must sign a declaration that their answers are true and authorize the sharing of medical information, and provide their printed name, signature and date. The questionnaire aims to obtain relevant health information from loan applicants.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    HEALTH QUESTIONNAIRE TO BE FILLED-UP BY PWA MEMBERS-BORROWERS

    (To be attached to the Loan Application Form)


    Have you been diagnosed, treated, medicated, and/or monitored for any of the
    conditions listed in the table below within the time frame specified?
    O Yes If YES, fill in the square/box next to the condition you have (or had) only if the
    applicable time frame applies to you.
    O No If NO, continue on the next section

    Fill-in for each condition you


    For which conditions have you been diagnosed, treated, medicated, have (or had)
    and/or monitored? In the last In the last 5
    12 months years
    1 Chronic Obstructive Pulmonary
    2 Cerebro-Vascular Accident or Cardio-Vascular Diseases
    3 Neuro-Surgical Conditions or Neurological Diseases
    4 Blood Dyscracias
    5 Cirrhosis of the Liver
    6 Poliomyelitis
    7 Autoimmune/Collagen Diseases (Systemic Lupus Erythematosus)
    8 Meningities
    9 Cancer
    10 Encephalitis
    11 Bodily injuries caused by violent accidental external and visible
    means
    12 Chronic Renal Diseases
    13 Others (Specify)

    I declare that the statements and answers contained herein are full, complete and true, and if
    found otherwise, I agree that condonation in case of death or permanent/total incapacity or
    disablement may not be granted to me. I hereby authorize any person or entity having a record or
    knowledge of my health to give to PWA all information relative to any hospitalization, medical
    treatment or consultation that I may have undergone.

    Please print name, then sign and date in the space provided.
    First Name M.I. Last Name

    ____________________________________
    Signature Date Signed

    THANK YOU FOR COMPLETING THE PWA HEALTH QUESTIONNAIRE

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