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El Perpetuo Socorro

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Name of applicant: *

E-Mail Address: *

NIE: *

Name of insured: *

NIE: *

Nationality: *

Language: *

Date of birth: *

Address: *

Town: *

Postcode: *

Telephone: *

Type of policy:

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Health Declaration for Medical Insurance

1. Do you suffer from any illness? Which?

2. Have you been hospitalized for medical or surgical treatment? Indicate date and reason

3. Are you being treated with any medicines, such as, analgesics, tranquillisers, diabetic or high blood pressure medication, antibiotics, anticoagulants for heart problems? Which?

4. Do you consume alcohol (how many units a day), tobacco (how many a day) or drugs?

5. Do you suffer from any after-effects from; Traffic accidents, accidental traumas or falls?

6. Have you undergone rehabillitation, physiotherapy, or radioactive treatment? For what reason?

7. Indicate if you suffer or have suffered from any of the following:

a. RESPIRATORY SYSTEM: Sinusitis, deviation of the nasal septum, aphonia, chronic bronchitis, lung tuberculosis, pneumonia, bronchial asthma or respiratory allergies, pleurisy. Have you had a Broncho-scope?

b. CIRCULATORY SYSTEM: Cardiac insufficiency, cardiac arrhythmia, heart attack, angina pectoris, hypertension, pericarditis, syncope, congenital heart or valve diseases such as mitral or aortic stenosis, stroke, pace maker, coronary by-pass, coronary graph (catheterism).

c. ARTERY ILLNESSES: Intermittent Claudication or aortic aneurysm; VEIN ILLNESSES: Varicose veins or phlebitis.

d. DIGESTIVE SYSTEM: Oesophagus, stomach, duodenum or instine ulcers, colitis, diarrhoea, chronic constipation, appendicitis, hiatus or groin hernias, hepatitis, jaundice, hepatic cirrhosis, billiary lithiasis (stones), blood comits or loss of blood in stools, haemorrhoids or anus fistulas, peritonitis, pancreatitis, inflamed intestine illness. Any other digestive illnesses?

e. NERVOUS SYSTEM: Chronic headache, insomnia, convulsions or paralysis. Psychological illnesses: Depressions, neurosis, psycosis, alcoholism, drug addiction, meningitis, encephalitis or neuritis. Parkinson Disease, dimetia. Discal hernias. Any other illnesses?

f. EAR, NOSE AND THROAT: Deafness, otitis, tonsilitis, adenoid vegetacions, vertigo, noise in ears.

g. EYE DISEASES: Myopia, hyperopia, presbyopia, astigmatism, squint, cataracts, glaucoma (high tension in eyes), conjunctivits, blindness, retina detachment. Have you undergone laser treatment?

h. BONES AND JOINTS: Acute or chronic rheumatism, arthrosis or srthritis, dislocations and fractures, rickets and discalcification, lumbago, sciatica, gout, palsy, bone tumors, traumatological operations, arthroscope (menicus), osteoporosis.

i. NEPHROLOGY AND UROLOGY: Kidney illnesses such as nephritis, renal tuberculosis, colics caused by kidney stones, cysts in kidneys, prostate problems, bladder illnesses. Have you undergone lithotrity?

j. SKIN DISEASES: Psoriasis, eczema, rashes, mycosis (fungus), skin allergies, skin and mucous tumors (lips and genitals).

k. ENDOCRINOLOGY: Diabetes, goitre or thyroid illnesses or illnesses of other glands such as pituitary or suprarenal, obesity, acetona.

l. INFECTIOUS DISEASES: Typhus, malta fever, meningitis, dysentry, leprosy, cholera, tuberculosis, syphilis, diptheria, malaria.

m. ONCOLOGY: Tumors or cancers in any part of the body.

n. HAEMATOLOGY (BLOOD DISEASES): Anaemia, harmorrhages, leukaemia, coagulation problems, Hodgkin's Disease, adenopathy (ganglion), rupture or removal of spleen, haemphilia.

o. GYNAECOLOGY AND OBSTERICS: Difficult births, caesarian section, premature births, menstruation problems, miscarriages or provoked abortions, genital or breast tumors. Are your pregnant? Any other female illnesses?

p. OTHER DISEASES: Toxic syndrome, A.I.D.S., occupational diseases, intoxications.

8. Indicate if you suffer or have suffered any other illnesses which do not appear in the health questionnaire.

9. Have you got national health cover in Spain?

10. Indicate person and telephone number in case of emergency.

Name

Telephone

I hereby authorise the Company to obtain any further information from any existing medical records and declare that the above health declaration is to my knowledge, true and correct and I hereby agree that the Company has the right to cancel the contract because of false declarations, in accordance with Article 10 of the Insurance Contract Law.

I agree *

I hereby authorise the Company to computerise all my personal details for exclusive use by the company under the protection of the consumers rights act (Law 15/1999, 13th December).

I agree *

The petition to rights of access, opposition, changes and cancellation of the details on record, must be made directly to the company's address.

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Health Declaration for Medical Insurance

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