Cuestionario de Salud de Asisa "*" indica campos obligatorios Este campo está oculto cuando se visualiza el formularioTomador del seguro Nombre Apellidos As part of Asisa's insurance requirements, all applicants must complete this health questionnaire before coverage can be processed.Nombre* Nombre Apellidos Fecha de nacimiento* DD barra MM barra AAAA NIF, NIE, o pasaporte*Género* HOMBRE MUJER Altura en centímetros*Por favor, escribe un número entre 50 y 240.Peso en kilogramos*Por favor, escribe un número entre 2 y 250.Este campo está oculto cuando se visualiza el formularioNumber of IndividualsPor favor, escribe un número entre 1 y 7. ¿Ha estado hospitalizado en un centro sanitario en los últimos 10 años, o tiene alguna hospitalización programada?* SI NO Por favor, indique el motivo y la(s) fecha(s):*2. ¿Se ha realizado alguna intervención quirúrgica, o tiene prevista alguna intervención quirúrgica?* SI NO Por favor, indique el motivo y la(s) fecha(s):*3. ¿Padece o ha padecido algún tumor o cáncer?* SI NO Por favor, especifique cuál y la(s) fecha(s) de diagnóstico*4. ¿Padece o ha padecido algún síntoma, dolor o trastorno de manera persistente, regular o recurrente, o se encuentra bajo supervisión o control médico por alguna razón?* SI NO Por favor, indique el motivo y la(s) fecha(s):*5. ¿Tiene o ha tenido alguno de los siguientes tipos de condición, lesión o trastorno?5.1 Cardíacas, vasculares, pulmonares o respiratorias (ej.: hipertensión, arritmias, insuficiencia cardíaca o circulatoria, varices, asma, enfisema, trombosis, etc.).* SI NO 5.2 Metabólicas (del sistema endocrino) o del sistema digestivo (ej.: del hígado o páncreas, úlcera gástrica o duodenal, hernias, diabetes, enfermedad tiroidea, etc.).* SI NO 5.3 Reumáticas, óseas o musculares (ej.: artritis, artrosis, escoliosis, hernia discal, fibromialgia, lupus, esclerodermia, trastorno muscular, secuelas de traumatismos, psoriasis, etc.).* SI NO 5.4 Del sistema nervioso, de los ojos o de los oídos (ej.: migrañas, epilepsia, enfermedad de Parkinson, parálisis, enfermedad de Alzheimer, glaucoma, degeneración macular, pérdida de visión, TDAH, etc.).* SI NO 5.5 Hematológicas o de coagulación (ej.: tromboembolismo, anemia, hemofilia, leucemia, etc.).* SI NO 5.6 Del riñón, del aparato urológico y genital, o ginecológicas (ej.: insuficiencia renal, problemas de próstata, cólico nefrítico, de transmisión sexual, ginecológicas - mama, útero, ovarios, etc.).* SI NO 5.7 Psiquiátricas (ej.: anorexia, bulimia, depresión, ansiedad, psicosis, esquizofrenia, etc.).* SI NO 5.8 Enfermedades infecciosas (ej.: hepatitis, COVID-19, tuberculosis, infecciones parasitarias, septicemia, enfermedades tropicales, etc.).* SI NO Por favor, indique cuál:*Other6. ¿Está tomando algún medicamento?* SI NO Especifique cuál, dosis y frecuencia (régimen):*7. ¿Consume alcohol, drogas o tabaco?* SI NO Indique el tipo, cantidad consumida y frecuencia:*8. ¿Tiene lesiones o secuelas de alguna enfermedad, trastorno congénito o hereditario, malformaciones o un accidente?* SI NO Por favor, indique cuál y proporcione un informe médico:*9. ¿Tiene reconocida alguna discapacidad o diversidad funcional, o está siendo evaluado/a para alguna?* SI NO Por favor, indique cuál y proporcione un informe médico:* Individual 2Name* Nombre Apellidos Date of birth* DD barra MM barra AAAA NIF, NIE, or Passport*Gender* MALE FEMALE Height in centimetres*Por favor, escribe un número entre 50 y 240.Weight in kilograms*Por favor, escribe un número entre 2 y 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* Nombre Apellidos Date of birth* DD barra MM barra AAAA NIF, NIE, or Passport*Gender* MALE FEMALE Height in centimetres*Por favor, escribe un número entre 50 y 240.Weight in kilograms*Por favor, escribe un número entre 2 y 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* Nombre Apellidos Date of birth* DD barra MM barra AAAA NIF, NIE, or Passport*Gender* MALE FEMALE Height in centimetres*Por favor, escribe un número entre 50 y 240.Weight in kilograms*Por favor, escribe un número entre 2 y 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* Nombre Apellidos Date of birth* DD barra MM barra AAAA NIF, NIE, or Passport*Gender* MALE FEMALE Height in centimetres*Por favor, escribe un número entre 50 y 240.Weight in kilograms*Por favor, escribe un número entre 2 y 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* Nombre Apellidos Date of birth* DD barra MM barra AAAA NIF, NIE, or Passport*Gender* MALE FEMALE Height in centimetres*Por favor, escribe un número entre 50 y 240.Weight in kilograms*Por favor, escribe un número entre 2 y 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* Nombre Apellidos Date of birth* DD barra MM barra AAAA NIF, NIE, or Passport*Gender* MALE FEMALE Height in centimetres*Por favor, escribe un número entre 50 y 240.Weight in kilograms*Por favor, escribe un número entre 2 y 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:* Firma* En su propio nombre Como titular de la póliza o familiar con mayoría de edad Nombre* Nombre Apellidos Su NIF, NIE, or pasaporte*Firma*Este campo está oculto cuando se visualiza el formularioQR EntryEste campo está oculto cuando se visualiza el formularioContract Entry (Asisa)Este campo está oculto cuando se visualiza el formularioNotification to support?Este campo está oculto cuando se visualiza el formularioExclude Workflow Δ
