Asisa Health Questionnaire "*" indicates required fields This field is hidden when viewing the formPolicyholder First Last As part of Asisa's insurance requirements, all applicants must complete this health questionnaire before coverage can be processed.Policy Holder 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.This field is hidden when viewing the formNumber of IndividualsPlease enter a number from 1 to 7. 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):*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:*Other6. 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:* Individual 2Name* 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):*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:*Other6. 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:* Individual 3Name* 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):*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:*Other6. 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:* Individual 4Name* 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):*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:*Other6. 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:* Individual 5Name* 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):*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:*Other6. 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:* Individual 6Name* 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):*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:*Other6. 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:* Individual 7Name* 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):*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:*Other6. 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*This field is hidden when viewing the formQR EntryThis field is hidden when viewing the formContract Entry (Asisa)This field is hidden when viewing the formNotification to support?This field is hidden when viewing the formExclude Workflow Δ
