CHEST PAIN QUESTIONNAIRE
(To be completed by the Life to be Assured)
Full name of life to be assured
Application number
1. Have you ever experienced a chest pain? Yes No
2. What was the date of the first attack of chest pain
3. How long did the pain last?
4. Have any attacks occurred subsequently? Yes No
If yes, please provide dates.
5. What was the nature and severity of the pain? e.g. very severe, crushing, vice-Iike, sharp, stabbing, dull ache, vague discomfort.
6. What was the location of the pain? e.g. central, in the left or right side of the chest, across the front of the chest, elsewhere
in the chest.
7. Did the pain radiate outside the chest? e.g. to the shoulders, arms, jaw, abdomen.
8. What was the mode of onset? e.g. sudden, gradual, at rest, only on exertion ceasing with rest, only with certain postures,
worsened by deep inspiration.
9. Were you given any treatment or undergo any investigations e.g. Stress Test? Yes No
If yes, please provide details including names of any medication.
10. Are you undergoing periodic preventive check-up for prevention of heart disease? Yes No
If yes, please provide all check-up reports.
11. Have your father, mother, brother, sister suffered from coronary artery disease? Yes No
If yes, please provide details like age, treatment details etc.
12. Have you been diagnosed as having
A. Hypertension (high blood pressure) Yes No B. Diabetes Yes No
COMP/DOC/Jun/2021/286/6121
C. Ischemic / Coronary Heart Disease Yes No D. Chronic Obstructive Lung Disease (COPD) Yes No
13. How many days you have been away from work due to chest pain?
14. Please provide any additional information on your condition, which will be helpful in processing your application.
I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material information
that may influence the assessment or acceptance of this application.
I hereby agree that the forgoing questions and answers shall form part of the proposal for insurance made by me to the Company.
Place: __________________
__________________________________________ __________________________________________
Date: ___________________
Signature of the Life to be Assured / Proposer Signature of the Medical Examiner / Code No.
