健康告知书-厦门大学人事处.doc

中英人寿保险有限公司福建分公司
福州市鼓楼区五四路136号中银大厦24层
电话：（86）0591 87849888 传真：（86）0591 87840609
团体保险被保险人健康告知书
Health Statement for Group Insurance Insurants
A、被保险人资料：
Information of Insurant:
投保人/ Company：
被保险人姓名/ Name：
被保险人与员工的关系：□配偶 □子女
The insured person and employee relations：□Spouse □child
附属被保险人姓名：
Name of the subsidiary insured：
身份证号码：
ID：
性别/ Gender：
年龄/Age：
B、健康告知：
Health Statement:
1、被保险人身高 cm，体重 pound/kg，过去两年内体重是否增减超过5公斤？
Height cm, Weight pound/kg; during the last two years, have you gained/lost weight for over 11bounds/5 kg?
□是Yes □否No
2、过去两年内是否曾因接受健康检查有异常情形而被建议接受其他检查或治疗？
During the last two years, have you ever been suggested to receive other kinds of physical examinations or treatments owing to some abnormal findings detected during your routine health examination?
□是Yes □否No
3、最近六个月是否曾因受伤或生病接受药物治疗、外科手术或服用药物？
During the most recent 6 months, have you ever taken pharmaceutical treatment, surgical operation or medicines owing to the cause of injury or sickness? If the answer is yes ,please give the reason.
□是Yes □否No
4、目前身体是否有失明、聋哑及言语、咀嚼障碍、四肢缺损、畸形及机能障碍？
Are you currently suffering from ablepsia, deafmutism, masticatory dysfunction, defect of extremities, deformity or functional disturbance?
□是Yes □否No
5、过去五年内，是否曾患有下列疾病，而接受治疗、诊疗或用药？
During the past five years, have you suffered from the following diseas