HEALTH DECLARATION FORM FOR PARENTS

Employee’s Name: ______________________________________________

Designation: _______________________________________________________
Company: ______ ___________________________________________________

Detail of Parents
DATE OF BIRTH
NAME Relation
(dd/mm/yyyy)
Father

Mother

IMPORTANT: Please
DESCRIPTION
A) Have any of your parents is suffering from the any of the below mentioned deceases.

(Please tick the relevant condition)?

1) Any Form of Cancer 2) Heart Disease/Disorder 3) Diabetes Mellitus 4) Stroke / Paralysis 5) Kidney
Disease 6) Abnormal Blood Pressure 7) Liver Disease 8) COPD/Asthma 9) High Cholesterol
10) Blood Disorder 11) Any Form of Hepatitis 12) Smoking or Any disease not mentioned here.

B) Have any of them was admitted to a hospital in the last 5 years due to any
disease/surgery/investigations?

C) Have you consulted a specialist doctor within the past 5 years for treatment of any of your parents?
If yes, give details of the illness/treatment.
_______________________________________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

D) Is your spouse already enjoying medical facility from any other organization?

If you have answered ‘YES’ to any of the above questions, please provide the details below. Use your
prescriptions/investigations/extra sheets if required.
Date & Duration of Name/Address of attending
Name Medical condition Procedure/Result
Treatment doctor/hospital

DECLARATION: I hereby declare that what has been stated above is true and complete to the best of my knowledge and belief and
I have not withheld any information. I hereby authorize any hospital, physician or surgeon who has attended me or my family to
furnish to the IGI Health Insurance, with any information they may require concerning our medical history or examinations.

Signature:_________________________________