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Request for new membership

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Previous Medical Scheme Information




MEDICAL DETAILS QUESTIONNAIRE

FAILURE TO DISCLOSE PRE-EXISTING CONDITIONS COULD LIMIT AND/OR EXCLUDE CERTAIN BENEFITS OR RESULT IN TERMINATION OF YOUR MEMBERSHIP
Did you or any of your dependents have any of the following operations, medical conditions or disorders during the past 12 months or received treatment, advice and/or medication for any of them. Please tick "Yes" or "No"
1. Diabetes, Heart Disease, Stroke, Cancer, Irregular menstruation cycle/abnormal menstrual bleeding, Hypertension and Cholesterol?
  

2. Taking medicine on an on-going basis or reasonably expecting to take medicine in the next 12 months?
  

3. Had any operations or admission to any hospital in the last 12 months?
  

4. Awaiting or planning any operation or admission to hospital (including pregnancy) for treatment in the next 12 months?
  

5. Is there any other condition or symptom, not detailed in any question above, for which medical advice, diagnosis, care or treatment has already been recommended or received, or could potentially result in a medical claim within 12 months?
  


ADDITIONAL INFO