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Please Answer the Self Health Declaration to continue further
1. Have you ever suffered from or are you sufering from or being treated for any of the following,
a) Diabetes, high blood sugar?
b) High blood pressure, chest pain or any heart disease?
c) Cancer, any tumor or lumps or enlarged glands?
d) Disease of the lungs such as shortness of breath, persistent cough, asthma, bronchitis?
e) Any disorder of blood, kidneys, stomach, liver, gall bladder, pancreas, intestines?
f) Any disease or disorder of deformity related to muscle, joints, limbs or spine?
g) Any neurogical (E.g. fits/epilepsy, frequent headches, fainting attacks) or psychiatric/mental illness (E.g. depression, schizophrenia)
h) Any loss of vision (other than corrected by spectacle or lens) or loss of hearing?
i) Any other disease / disorder not mentioned above?
2. Are you presently taking medications (other than vitamins or supplements)?
3. In the past 12 months, have you undergone any surgical operation or any investigations such as but not limited to ECG, blood tests, biopsies, MRI/CT scan, etc or have you been advised to under to go any surgery or medical procedure?
4. Have two or more of your immediate family members (Father, Mother, Brother and Sister) died or suffered from heart disease, cancer, kidney disease before the age of 60 or suffered from any familial or hereditary disorder?
5. Has your proposal for Life/Health Insurance ever been declined/accepted with Restriction or Extra rates?
6. Previous medical/surgical hospitalisations, procedures and operations
7. Any Chronic diseases, symptoms and complaints not mentioned above
8. Any Pre-existing diseases, symptoms and complaints not mentioned above

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Please draw or sign inside the below signature box before proceeding further
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I agree, confirm that all declaration and statement about my health is true.I have read and understood the benefits, exclusions and hospital network of this policy.
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