Sanitas Additional Questionnaire "*" indicates required fields This questionnaire must be completed for each beneficiary who declares health problems. In case of organ and/or tissue extraction, the pathological anatomy must also be provided, as well as the medical report with the current situation. If you have medical reports of the declared problems, attach them.This field is hidden when viewing the formQR EntryThis field is hidden when viewing the formCompañiaInsured Name* Full legal first name Full legal last name(s) ID Number*Weight in kilograms*Height in centimetres*Do you have any optical refractive defect? (myopia, hypermetropia, astigmatism, etc.):*Diopters right eye*Diopters left eye*Number of Medical Aspects to declare*Please enter a number from 1 to 4. Description of Declared Medical Aspect No11. Cause (e.g., due to illness, after an accident, congenital, due to pregnancy, etc.). Specify*Indicate is current or past problem?* Current Past Starting Date* DD slash MM slash YYYY End Date* DD slash MM slash YYYY 2. Exact location (e.g., left leg, right arm, ears, etc.). Specify*3. Treatment if there has been any, indicate type: medical, surgical, etc. Specify.*4. Prostheses or implanted surgical material (e.g., Osteosynthesis: nails, screws, meshes, etc.). Specify.*5. Diagnostic tests and/or treatments planned for the future. Specify.*6. Current situation regarding the declared medical aspect and specify possible sequelae (e.g., cured, minor discomfort, limping, etc.).*Please attach relevant medical report(s) if available Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, Max. file size: 5 MB, Max. files: 5. Description of Declared Medical Aspect No21. Cause (e.g., due to illness, after an accident, congenital, due to pregnancy, etc.). Specify*Indicate is current or past problem?* Current Past Starting Date* DD slash MM slash YYYY End Date* DD slash MM slash YYYY 2. Exact location (e.g., left leg, right arm, ears, etc.). Specify*3. Treatment if there has been any, indicate type: medical, surgical, etc. Specify.*4. Prostheses or implanted surgical material (e.g., Osteosynthesis: nails, screws, meshes, etc.). Specify.*5. Diagnostic tests and/or treatments planned for the future. Specify.*6. Current situation regarding the declared medical aspect and specify possible sequelae (e.g., cured, minor discomfort, limping, etc.).*Please attach relevant medical report(s) if available Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, Max. file size: 5 MB, Max. files: 5. Description of Declared Medical Aspect No31. Cause (e.g., due to illness, after an accident, congenital, due to pregnancy, etc.). Specify*Indicate is current or past problem?* Current Past Starting Date* DD slash MM slash YYYY End Date* DD slash MM slash YYYY 2. Exact location (e.g., left leg, right arm, ears, etc.). Specify*3. Treatment if there has been any, indicate type: medical, surgical, etc. Specify.*4. Prostheses or implanted surgical material (e.g., Osteosynthesis: nails, screws, meshes, etc.). Specify.*5. Diagnostic tests and/or treatments planned for the future. Specify.*6. Current situation regarding the declared medical aspect and specify possible sequelae (e.g., cured, minor discomfort, limping, etc.).*Please attach relevant medical report(s) if available Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, Max. file size: 5 MB, Max. files: 5. Description of Declared Medical Aspect No41. Cause (e.g., due to illness, after an accident, congenital, due to pregnancy, etc.). Specify*Indicate is current or past problem?* Current Past Starting Date* DD slash MM slash YYYY End Date* DD slash MM slash YYYY 2. Exact location (e.g., left leg, right arm, ears, etc.). Specify*3. Treatment if there has been any, indicate type: medical, surgical, etc. Specify.*4. Prostheses or implanted surgical material (e.g., Osteosynthesis: nails, screws, meshes, etc.). Specify.*5. Diagnostic tests and/or treatments planned for the future. Specify.*6. Current situation regarding the declared medical aspect and specify possible sequelae (e.g., cured, minor discomfort, limping, etc.).*Please attach relevant medical report(s) if available Drop files here or Select files Accepted file types: jpg, png, pdf, jpeg, Max. file size: 5 MB, Max. files: 5. Signature Δ
