High BP

High Blood Pressure Questionnaire – 3.
We thank you for applying for an HDFC Life Insurance Policy. To enable us to assess your
application, kindly send this High Blood Pressure Questionnaire answered by the Life to be Assured and
duly signed by the Life to be Assured and Proposed Policy Holder, if any.
Please note: Wherever examples are provided, they are not intended to be complete list.
Application No / Proposal No
Name of Life to be Assured in full
1. Have you ever been diagnosed with high blood pressure/ Yes / No
hypertension?
(Please answer 'Yes' or ‘No’)
Please answer all the following questions, only if the answer to above question is 'Yes'.
If the answer is 'No' then please return the form duly signed.
2. When was high blood pressure/ hypertension first
diagnosed?
3. What was the cause/reason for which your blood pressure
was measured at the time of diagnosis?
E.g. routine examinations, due to symptoms etc.

4. What was your blood pressure reading recorded at the time
of diagnosis?
5. Have you ever undergone an ECG, X-Ray, blood sugar Yes / No
test, Hba1c, blood lipid test or other investigations?
If yes, please provide name of investigation(s)

undergone and results thereof.
(Kindly attach copies of all investigation reports)

6. Please provide details of treatment prescribed including Current
name(s) of medication, dosage and frequency.
E.g. Aten, Amdepin, Telma, Enam, Natalix, etc.
Past
7. Kindly answer following regarding the monitoring of your condition.

7.a.Name, address and contact number of the doctor in
charge of your follow-up.
7.b. How often do you attend a follow-up?
7.c. When was your last consultation?
Please mention your blood pressure reading at that time.
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8. Have you ever been diagnosed with any of the following? Yes No
If Yes, please tick diagnosed condition/health ailment from below list.

a. Retinopathy d. Giddiness
b. Diabetes e. Protein or albumin in the urine
c. Heart or circulatory problems f. High level of cholesterol
9. Do you smoke cigarettes/ bidis / any other form of

Yes / No
tobacco etc?
Per day ___________ units
If yes, how many do you smoke per day?
10. Do you consume alcohol?
Yes / No
If yes, state the type of alcohol you consume and your
average weekly intake of quantity.
(Please note:125 ml of wine = 1 unit equivalent
330 ml of beer = 1 unit equivalent and Per day ___________ units
30 ml of any other spirit = 1 unit equivalent)
11. Have you ever been hospitalised or lost significant time off
Yes / No
work on account of elevated blood pressure/hypertension?
If yes, kindly enclose discharge summary and treatment

received.
12. Please provide any additional information apart from the
above, which will enable us in better assessment of the
application form.
An incomplete Questionnaire will not be considered valid
Declaration of Life to be Assured:
I agree and understand that the information given herein is true and complete in all respects and will form an
integral part of the proposal made by me for an insurance policy from HDFC Life Insurance Company Limited and
that failure to disclose any material fact known to me may invalidate the contract.
Signature/thumb impression
Date:…………………………….
(Life to be Assured)
Place:……………………………
Signature/thumb
impression(Proposed Policy Date:…………………………….
Holder if different from Life to be Place:……………………………
Assured)
In the case of thumb impression\ signature in vernacular language:

In case of thumb impression of the Life to be Assured the same should be attested by a person of standing whose
identity can be easily established, but unconnected with the Company and this declaration should be made by him.
I hereby declare that I have explained the contents of this form to the Life to be Assured in ________ language and
have truthfully recorded the answers provided to me and that the Life to be Assured has signed /affixed thumb
impression(s) above after fully understanding the contents thereof.
Signature Date:……………………………
Place:………………………….
Name and address of the declarant
HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life).
CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
For queries or more information, call us on 1860-267-9999 (Local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
Email - [email protected] | [email protected] (For NRI customers only) | Visit - www.hdfclife.com
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High Blood Pressure Questionnaire – 3.

E.g. routine examinations, due to symptoms etc.

If yes, please provide name of investigation(s)

(Kindly attach copies of all investigation reports)

7. Kindly answer following regarding the monitoring of your condition.

7.b. How often do you attend a follow-up?

7.c. When was your last consultation?

Please mention your blood pressure reading at that time.

If Yes, please tick diagnosed condition/health ailment from below list.

9. Do you smoke cigarettes/ bidis / any other form of

If yes, kindly enclose discharge summary and treatment

In the case of thumb impression\ signature in vernacular language:

Name and address of the declarant

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