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Health
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Personal Data
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Surname
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First name
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Date of birth
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Address
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(Postal code, town, street)
Phone number
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E-Mail
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NIE or passport number of the applicant
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Gender
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Female
Male
Do you have a previous insurance police?
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Which tariff would you like to receive information from?
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Tariff D (with free choice of doctor)
Tariff E71 (Medical care without copayment)
Both
Health Data
Allergies
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Yes
No
If yes, specify date and treatment
Cardiovascular diseases
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Yes
No
If yes, specify date and treatment
Heart Attack
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Yes
No
If yes, specify date and treatment
Angina
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Yes
No
If yes, specify date and treatment
Varicose veins
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Yes
No
If yes, specify date and treatment
Skin disease
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Yes
No
If yes, specify date and treatment
Digestive diseases
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Yes
No
If yes, specify date and treatment
Ulcer in the stomach or duodenum
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Yes
No
If yes, specify date and treatment
Diaphragmatic hernia
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Yes
No
If yes, specify date and treatment
Endocrine disorders
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Yes
No
If yes, specify date and treatment
Diabetes
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Yes
No
If yes, specify date and treatment
Goiter
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Yes
No
If yes, specify date and treatment
Gout disorders
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Yes
No
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Urogenital diseases
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Yes
No
If yes, specify date and treatment
Renal colic (stones)
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Yes
No
If yes, specify date and treatment
Hysterectomy (removal of the uterus/ovaries)
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Yes
No
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Renal insufficiency
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Yes
No
If yes, specify date and treatment
Liver disease
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Yes
No
If yes, specify date and treatment
Hepatitis
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Yes
No
If yes, specify date and treatment
Cirrhosis
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Yes
No
If yes, specify date and treatment
Biliary colic, liver colic or gallstones
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Yes
No
If yes, specify date and treatment
Diseases of bone/muscle
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Yes
No
If yes, specify date and treatment
Disc prolapse
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Yes
No
If yes, specify date and treatment
Rheumatism
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Yes
No
If yes, specify date and treatment
Arthrosis
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Yes
No
If yes, specify date and treatment
Osteoporosis
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Yes
No
If yes, specify date and treatment
Knee and meniscus injuries
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Yes
No
If yes, specify date and treatment
Neurological diseases
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Yes
No
If yes, specify date and treatment
Brain embolism/thrombosis
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Yes
No
If yes, specify date and treatment
Epilepsy
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Yes
No
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Meningitis
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Yes
No
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Paralysis
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Yes
No
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Depression
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Yes
No
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Other neurological diseases
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Yes
No
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Diseases of the respiratory tract
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Yes
No
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Asthma
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Yes
No
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Chronic Bronchitis
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Yes
No
If yes, specify date and treatment
Pneumonia
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Yes
No
If yes, specify date and treatment
Tuberculosis
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Yes
No
If yes, specify date and treatment
High blood pressure
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Yes
No
If yes, specify date and treatment
Tumours
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Yes
No
If yes, specify date and treatment
Eye disorders and visual disturbances
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Yes
No
If yes, specify date and treatment
Diseases or disorders of the nose
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Yes
No
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Suffering or suffered from diseases that are not listed
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No
If yes, specify date and treatment
Suffering or suffered injuries affecting physical disorders
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Yes
No
If yes, specify date and treatment
The impact and/or limitations associated with the disease (disability, etc.)
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Which consequences
Consumption of tobacco
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Yes
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What kind of tobacco (cigarettes/cigar/pipe) and quantity per day
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Do you take any medicine?
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Nature and reason(s)
Take a drug?
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Specify the type
Have you ever suffered an injury or accident?
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Yes
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What consequences?
Past surgical procedures
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Please indicate date, diagnosis and consequences of the procedure
Have you had an HIV test?
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Specify date
Have you seen a doctor in the last 6 months?
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Yes
No
Specify reason(s)
Have you had an examination with diagnosis or before a treatment?
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No
Specify which one
Please enter your weight in kilogrames
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Please enter your height in centimetres
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