Super HealthCare & Arogya Sanjeevani Insurance
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Contact
2
Product
3
Member Info
4
Medical,Discount &
Add-on’s
5
Payment
6
Address & Nominee
1
Contact
2
Member Info
3
Medical,Discount
& Add-on’s
4
PAYMENT
5
Address & Nominee
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Select your age-band
18yrs-35yrs
36yrs-45yrs
46yrs-50yrs
51yrs-55yrs
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If you have selected No above then all below questions will be No
1. High or low blood pressure, Chest pain, or any other cardiac disorder.
2. Tuberculosis, Asthma, Bronchitis or any other lung/respiratory disorder.
3. Ulcer (Stomach/Duodenal), Liver or gall bladder disorder or any other digestive tract disorder.
4. Kidney Failure, Stone in kidney or urinary tract, Prostate disorder or any other kidney/urinary tract disorder.
5. Stroke, Epilepsy (fits), Paralysis or any other nervous system (Brain, Spinal Cord, etc.) disorder.
6. Diabetes, Impaired glucose tolerance (pre-diabetes), Thyroid/Pituitary Disorder or any other endocrine disorder.
7. tumour (swelling) benign or malignant, any external ulcer />growth/cyst/mass anywhere in the body
8. Arthritis, Spondylosis or any other disorder of the muscle/bone/joint.
9. Diseases of the Ear/Nose/Throat/Teeth/Eye (please mention Dioptres in case of refractory error).
10. HIV/AIDS or sexually transmitted diseases or any immune system disorder.
11. Anaemia, Leukaemia, Lymphoma or any other blood/ lymphatic system disorder.
12. Psychiatric/Mental Illnesses or Sleep disorder.
13. Uterine Fibroid, Fibro adenoma breast or any other Gynaecological (Female reproductive system)/Breast disorder.
14. Been addicted to alcohol, narcotics, and habit forming drugs or been under detoxication therapy?
15. Been under any regular medication (self/prescribed)?
16. Undertaken any lab/blood tests, imaging tests viz. scans/MRI in the last 5 years other than routine health check-up or
pre-employment check-up?
17. Undertaken any surgery or a surgery been advised and have surgery still pending?
18. Suffered from any other diseases/illness/accident /injury other than common cold or fever?
19. Is anyone currently pregnant?
20. Any complaint of diabetes, hypertension or any complication during current or earlier pregnancy?