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FirstChoice – High Blood Pressure Questionnaire

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					  FirstChoice – High Blood
  Pressure Questionnaire
  Supplementary Personal Statement

   Full name of Life to be Insured


   Date of birth of Life to be Insured       Account number
             /    /


  Questions should be completed in respect of the Life to be Insured
1 Date condition first started                                                                                                                            /     /

2 Date condition ceased                                                                                                             /      /         or        Ongoing

3 What caused this condition?




4 Have you ever taken medication for this condition?                                                                                                      No         Yes

  If ‘Yes’:
  Please provide us with the following information:
  a Name and dosage



  b Are you still taking medication?                                                                                          No          Go to i below         Yes

       If ‘No’:

       i When did you cease taking medication?                                                                                                            /     /

5 Is your blood pressure regularly monitored by your doctor?                                                                                              No         Yes

6 Date of last blood pressure reading                                                                                                                     /     /

7 Result of last blood pressure reading, e.g. 130/80?


8 Does your usual doctor have knowledge of this condition?                                                                                                No         Yes
  If ‘No’:
  Please provide the following details:
   Name of doctor


   Address of doctor


   Phone number of doctor                Fax number of doctor
   (     )                               (    )

  I confirm that the above information is true, correct and complete.
   Signature of Life to be Insured                   Date
                                                            /      /




                        Please send completed form to: Colonial First State, Reply Paid 27, Sydney NSW 2001.



  002-377 110106                                                                                                                                              Page 1 of 1

                                     CommInsure is a registered business name of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).

				
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Description: FirstChoice – High Blood Pressure Questionnaire