Drug Abuse Questionnaire Form

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HSBC Insurance (Singapore) Pte. Limited.
(Reg. No. 195400150N)
21 Collyer Quay #02-01 Singapore 049320, Monday to Friday 9.30am to 5pm.
Customer Care Hotline: (65) 6225 6111 Fax: (65) 6221 2188
Mailing address: Robinson Road Post Office P.O. BOX 1538 Singapore 903038.
Drug Abuse Questionnaire
WARNING:
Statement Pursuant to Section 25(5) of the Insurance Act, you are to disclose in this form, fully and faithfully, all the facts which
you know or ought to know, otherwise the request effected hereunder may be void.
Proposal no
:_____________________________________
Name of life insured/participant
:_____________________________________
Name of policyowner/certificate holder
:_____________________________________
(if other than life insured/participant)
1. Please indicate which of the following substances you have ever tried or used:
i) Amphetamines (speed, uppers, dexies, crystal meth, ice, etc)
Yes ____
No___
ii) Anabolic steroids (roids, gear, juice, etc)
Yes ____
No___
iii) Barbiturates (amytal, phenobarbital)
Yes ____
No___
iv) Cannabis (marijuana, dope, hooch, grass, pot, hashish, THC, etc)
Yes ____
No___
v) Cocaine (coke, blow, snow, crack, etc)
Yes ____
No___
vi) Estacy (meth amphetamine, MDMA, ecky, E’s, etc)
Yes ____
No___
vii) Opiates (codeine, heroin, methadone, morphine, pethidine, smack, etc)
Yes ____
No___
viii) Psychedelics (magic mushrooms, LSD, acid, etc)
Yes ____
No___
ix) Solvents (glue, aerosol, thinners, nitrous oxide, petrol, etc)
Yes ____
No___
x) Others: (Please specify) _____________________
Yes ____
No___
Name of substance
Date of first used
Date ceased
Frequency of use
2. Have you ever injected or used drugs intravenously?
Yes ____
No___
If “Yes”, please provide details including dates.
_________________________________________________________________________________________
3. Have you ever been tested for Hepatitis B, Hepatitis C or HIV?
Yes ____
No___
If “Yes”, please provide details including dates and results.
_________________________________________________________________________________________
4. Have you ever sought medical advice or been referred for drug counselling?
Yes ____
No___
If “Yes”, please provide details including full name and address of doctor with date of last consultation.
_________________________________________________________________________________________
5. Have you ever been hospitalised or treated for a drug overdose?
Yes ____
No___
If “Yes”, please provide details including full name and address of doctor with date of last consultation.
_________________________________________________________________________________________
6. Have you ever suffered any medical condition or impairment related to your
Yes ____
No___
drug use? (e.g. Hepatitis, HIV, mental health disorder, etc).
If “Yes”, please provide details including dates and results of investigations done.
_________________________________________________________________________________________
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HSBC Insurance (Singapore) Pte. Limited
10 Eunos Road 8, #11-01 Singapore Post Centre (South Lobby), Singapore 408600
Tel: (65) 6225 6111 Fax: (65) 6221 2188
Web site:
Company registration no. 195400150N
SGI NB SUQ_v1.0 May 2011

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