Diabetes Questionnaire Form
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1
2HSBC 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.
Diabetes 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. When was your diabetes condition first diagnosed? (State the year or age of onset.)
_________________________________________________________________________________________
2. Are you currently or previously on any treatment/medication as per stated below?
(a) Diet control
Yes ____
No___
If “Yes”, please provide detailed description.
_________________________________________________________________________________________
(b) Oral Medication
Yes ____
No___
If “Yes”, please provide name of medications, dosage, frequency and date last taken.
_________________________________________________________________________________________
(c) Insulin
Yes ____
No___
If “Yes”, please provide dosage, frequency and date last taken.
_________________________________________________________________________________________
3. Do you check your urine on a regular basis?
Yes ____
No___
If “Yes”, please state frequency (e.g. Daily, weekly, fortnightly, others.) and results.
_________________________________________________________________________________________
4.
Have there been any tests or investigations carried out?
Yes ____
No___
(e.g Blood test, urine test, ECG, etc)
If “Yes”, please state the date, results and submit copies of the investigations report, if any.
Type of Test
Date of Test
Result of Test
Fasting Blood Glucose
____/____/20____
___________ (mmol / mg/dl)
HbA1c Test
____/____/20____
___________ (%)
Urine Feme/Microurinalysis
____/____/20____
___________ (any presence of glucose, protein)
Others
____/____/20____
___________
5. Are you currently or previously on follow up?
Yes ____
No___
If “Yes”, please state date of last consultation and/or next appointment.
_________________________________________________________________________________________
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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
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