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Insurance.hsbc.com.sg

HSBC Insurance (Singapore) Pte. Limited. (Reg. No. 195400150N)
21 Collyer Quay #02-01 Singapore 049320, Monday to Friday 9.30am to 5pm. www.insurance.hsbc.com.sg.
Customer Care Hotline: (65) 6225 6111 Fax: (65) 6221 2188
Mailing address: Robinson Road Post Office P.O. BOX 1538 Singapore 903038.
Chest Pain Questionnaire
WARNING: Statement Pursuant to Section 25(5) of the Insurance Act, you are to disclose in this form, fully and faithfully, all the facts which
you know or ought to know, otherwise the request effected hereunder may be void.
(if other than life insured/participant) 1. Pertaining to the pain experienced, please provide details on the following: (a) Date of first episode and last episode: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 2. Please state location of the pain or discomfort, (e.g. whether in middle or on the left or right side of the chest, radiating to the left or right arm, or elsewhere). _________________________________________________________________________________________ 3. Please describe the nature of your chest complaints/symptoms (e.g. stabbing pain, numbness, burning pain, _________________________________________________________________________________________ 4. When does it usually occurs (e.g. on exertion, with exercise, excitement, after food, at rest, suddenly or at _________________________________________________________________________________________ 5. What was the exact diagnosis and underlying cause told by the doctor? _________________________________________________________________________________________ 6. Have there been any tests or investigations carried out? (e.g. Blood tests, chest x-rays, coronary angiogram, echocardiograph, electrocardiograph, stress test, etc) If “Yes”, please state the date, results and submit copies of the investigations report, if any. _________________________________________________________________________________________ HSBC Insurance (Singapore) Pte. Limited
10 Eunos Road 8, #11-01 Singapore Post Centre (South Lobby), Singapore 408600 Web site: www.insurance.hsbc.com.sg Company registration no. 195400150N 7. Are you currently or previously on any treatment/medication? If “Yes”, please provide name of medication, dosage, frequency and date last taken. (a) Trinitrates (to place under the tongue): _________________________________________________________________________________________ (b) Treatment to cause thinning of the blood (e.g. Warfarin, Aspirin): _________________________________________________________________________________________ _________________________________________________________________________________________ 8. Have you ever been hospitalised due to this condition? If “Yes”, please state the date of admission, duration of stay and full name of hospital. _________________________________________________________________________________________ 9. Are you currently or previously on follow up? If “Yes”, please state date of last consultation and/or next appointment. _________________________________________________________________________________________ 10. Have your working duties and/or sports/exercise ever been affected or If “Yes”, please provide details including description of restriction and durations. _________________________________________________________________________________________ 11. Please provide full name and address of the doctor whom you have consulted for this condition. _________________________________________________________________________________________ I declare that to the best of my knowledge and belief, the information given by me is true and complete and that no material facts (i.e. facts likely to influence the assessment and acceptance of my proposal for the life insurance) I agree that this form shall constitute a part of my proposal for Life Insurance with HSBC Insurance (Singapore) Signature of policyowner/certificate holder (if other than life insured/participant) HSBC Insurance (Singapore) Pte. Limited
10 Eunos Road 8, #11-01 Singapore Post Centre (South Lobby), Singapore 408600 Web site: www.insurance.hsbc.com.sg Company registration no. 195400150N

Source: http://www.insurance.hsbc.com.sg/1/PA_ES_Content_Mgmt/content/SGHI/service/forms/images/chestpain.pdf

October 2003 report

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