4th Floor Gordon House, 1 Coney Drive
Toll Free: 0-800-543-3734
Make A Claim
|
Get Quote
Home
About Us
Who We Are
Our Team
Our Sales Agents
Plans
Life Plans
Health Insurance
Business Solutions
Payment Options
Credit/Debit Card
Online Payments
Digital Wallet
Blog
News
Forms
Frequently Asked Questions
Glossary
Contact Us
Asthma Questionnaire
Home
Forms
Asthma Questionnaire
Asthma Questionnaire
"
*
" indicates required fields
Email
This field is for validation purposes and should be left unchanged.
Full Name of Insured
*
First
Middle
Last
Date of Birth
*
1. At what age did your asthma commence?
*
2. Date asthma/reactive airway disease (RAD) diagnosed:
*
3. Type of asthma:
*
Extrinsic (allergic)
Chronic
Intrinsic (late onset)
Bronchial
Exercise Induced
Status Asthmaticus
Other (please explain)
Provide details about Asthma
4. How frequently do these episodes occur?
*
5. Do you receive treatment for these episodes?
*
Yes
No
6. Nature of treatment (bronchodilators, aerosol inhalants, steroid therapy).
*
7. Do you receive treatment only during episodes or is the treatment continuous?
*
8. Is your chest clear between episodes?
*
Yes
No
9. Have you ever experienced any limitation of ability to work or been absent from work as a result of an episode?
*
Yes
No
If no, please provide details of
If “YES”, please state number of days.
10. Has hospitalization been necessary?
*
Yes
No
11. Have you ever had your chest X-rayed or undergone any pulmonary function tests?
*
Yes
No
List hospitalization dates:
If Yes, please state date and results
12. Please state any further details you feel may be relevant.
Signature of Client
Signature of Client
Date
*
Date
hCaptcha
Δ