Insurance Health Risk Assessment Declaration
Full Name
Date of Birth
Address
Contact Number
Email
Health Declaration
1. Do you have any of the following conditions? (select all that apply)
Diabetes
Hypertension
Heart Disease
Respiratory Issues
Other
If "Other", please specify
2. Are you currently taking any medication?
Yes
No
If yes, please specify
3. Do you have any allergies?
Yes
No
If yes, please specify
4. Have you had any major surgery in the past 5 years?
Yes
No
If yes, please provide details
5. Family history of genetic/serious illnesses (specify relationship and illness)
Lifestyle Information
6. Do you smoke?
Yes
No
7. Do you consume alcohol?
Yes
No
8. Exercise frequency (per week)
0 times
1-2 times
3-4 times
5+ times
Declaration & Acknowledgement
I hereby declare that the information provided above is true and correct to the best of my knowledge.
Signature
Date