Asisa Health Questionnaire "*" indicates required fields HiddenPolicyholder First Last Name* First Last Date of birth* DD slash MM slash YYYY NIF, NIE, or Passport* Gender* MALE FEMALE Height in centimetres*Please enter a number from 50 to 240.Weight in kilograms*Please enter a number from 2 to 250. 1.Have you been admitted to a health centre in the last 10 years, or do you have any admissions scheduled?* YES NO Please indicate the reason and the date(s):*2.Have you undergone any surgery, or are you scheduled to undergo any surgery?* YES NO Please indicate the reason and the date(s):*3. Do you have or have you had any tumours or cancer?* YES NO Please specify which and the date(s) of diagnosis*4. Have you or have you had any symptoms, pain or disorder persistently, regularly or recurringly, or are you under medical supervision or monitoring for any reason?* YES NO Please indicate the reason and the date(s):* 5. Have you or have you had any of the following types of condition, injury or disorder?5.1 Cardiac, vascular, pulmonary or respiratory (e. g.: hypertension, arrhythmias, heart or circulatory failure, varices, asthma, emphysema, thrombosis, etc.).* YES NO 5.2 Metabolic (of the endocrine system) or of the digestive system (e. g.: of the liver or pancreas, gastric or duodenal ulcer, hernias, diabetes, thyroid disease, etc.).* YES NO 5.3 Rheumatic, bone or muscular (e. g.: arthritis, osteoarthritis, scoliosis, slipped disc, fibromyalgia, lupus, scleroderma, muscle disorder, trauma sequelae, psoriasis, etc.).* YES NO 5.4 Of the nervous system, of the eyes or of the ears (e. g.: migraines, epilepsy, Parkinson's disease, paralysis, Alzheimer's disease, glaucoma, macular degeneration, vision loss, ADHD, etc.).* YES NO 5.5 Haematological or clotting (e. g.: thromboembolism, anaemia, haemophilia, leukaemia, etc.).* YES NO 5.6 Of the kidney, urological and genital tract, or gynaecological (e. g.: kidney failure, prostate problems, renal colic, sexually transmitted, gynaecological - breast, uterus, ovaries, etc.).* YES NO 5.7 Psychiatric (e. g.: anorexia, bulimia, depression, anxiety, psychosis, schizophrenia, etc.).* YES NO 5.8 Infectious diseases (e. g.: hepatitis, COVID-19, tuberculosis, parasitic infections, septicaemia, tropical diseases, etc.).* YES NO Please indicate which:* 6. Do you take any medication?* YES NO Indicate which, dose and frequency (regimen):*7. Do you consume alcohol or drugs or do you smoke?* YES NO Indicate the type, amount consumed and frequency:*8. Do you have lesions or sequelae from a disease, congenital or hereditary disorder, malformations or an accident?* YES NO Please indicate which and provide a medical report:*9. Do you have any recognised handicap or disability, or are you in the process of being assessed for any?* YES NO Please indicate which and provide a medical report:* Signing* In your own name As a policy contracting party or family member of legal age Name* First Last Your NIF, NIE, or Passport* Signature*HiddenQR EntryHiddenNotification to support? Δ
