Sex M/F PM Height in cm Weight in kg DV Smoking yes/no Occupation Subscriber Spouse Child 1 Child 2 Child 3 Child 4 If a dependent of yours is not applying for coverage, please state the reason: Yes 1 Circulatory or Heart disease (high blood pressure, arrhythmia, murmur, infarction etc.) 2 Respiratory disease or Allergy (asthma, bronchitis, emphysema, pneumonia, tuberculosis etc.) 3 Digestive disease (constipation, diarrhea, hepatitis, ulcers, pancreatitis etc.) 4 Renal or Urinary disease (nephritis, stones, renal colic, albuminuria, hematuria…) 5 Osteo-articular disease, disease of Hip or Vertebral column (scoliosis, rheumatism, slipped disc etc.) 6 Neurological, Cerebral, or Muscular disease (epilepsy, meningitis, aneurysm, paralysis etc.) 7 Endocrinal or Metabolic disease (goiter, nodules, diabetes, cholesterol, gout etc.) 8 Eye, Nose Throat disease (glaucoma, retinopathy, dizziness, otitis, laryngitis, sinusitis etc.) 9 Blood, Ganglionic or Skin disease (anemia, hemophilia, adenopathy, eczema, herpes, purpura etc.) No 10 Sexual disease (AIDS, gonorrhea, syphilis etc.) 11 Tumors or Swelling (fibroma, cyst, lipoma, cancer etc.) 12 Any other disease, past or future operation, Accident or Treatment not mentioned above 13 Psychical disease (nervous depression, fatigue, insomnia, psychosis etc.) 14 For female applicants, are you pregnant If yes please state the expected due date 15 Congenital anomalies, Hereditary/Genetic diseases If you answered Yes to any of the above questions, please give full details here below: Name Date Hospital Details I authorize my doctor, health institute or other organization or person that has any information about my health and/or activities (and those of my Dependants) to provide ASSUREX SAL and/or NEXTCARE SAL with the said information..
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