Anxiety Depression Questionnaire

Anxiety/Depression Questionnaire
Name Of Proposed Insured: ............................................................................................................................
Policy no.: ....................................................................................... Dated:................................................
1) Please state exact diagnosis.(e.g. depression, schizophrenia, neurosis, phobia etc) If other, please
provide details Yes No
Depression ....................................................
Anxiety .…………….............................
Schizophrenia .………………..........................
Other ..................................................
.......................................................................................................................................................
2) Date of first occurrence of the medical condition? ................................................
3) Name of main doctor attended for the medical condition?

........................................................................................................................................................
4) Was your condition related to any particular event?.....................................................................
5) What were the presenting symptoms first noted and ongoing symptoms, if any?
...........................................................................................................................................................
6) Date you last attended the doctor for this condition?
............................................................................................................................................................
7) Do you still receive treatment or suffer any symptoms? Yes No

If “No” how long has it been since you been free of all symptoms?
...........................................................................................................................................................
8) What treatment have you received? If other, give details:

Medication Hospitalisation ECT Counseling Other
.......................................................................................................................................................
9) Please can you provide details which include frequency and duration of the medication? Please
give details of both past and present medication.
Past Medication: ..........................................................................................................................

Current Medication: .....................................................................................................................
Tata AIA Life Insurance Company Limited

.(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/238
10) Have you ever been hospitalized as an in-patient or Out-patient or had electro-convulsive therapy
(ECT)? If Yes, please provide details Yes No
……………………………………………………........................................................................
11) Did you require time away from your usual occupation? Yes No
If yes, how long
2 weeks 2-4 weeks >4 weeks
12) Have you ever attempted or contemplated committing suicide? Yes No

If yes give details.
........……………………………………………………………………………………................
13) Does your condition interfere to any degree with your ability to carry out your occupation? If yes
please provide details.
...........................................................................................................................................................
14) Please provide copies of Medical reports if you have any. ............................................................
I hereby declare and agree that the above particulars and answers are complete and true, and this
questionnaire will form part of the contract of the desired insurance of my life. I hereby irrevocably
authorize any organization, institution or individual that has any record or knowledge of my/the insured’s
health and medical history to disclose such information or provide such medical records to Tata AIA.
Signature of Proposed insured:______________________ Date:____________________
Signature of Applicant:______________________ Date:____________________

(If applicant is different from the proposed insured)
VERNACULAR DECLARATION:
In case the Proposed Insured/Applicant affixes a thumb impression or signs in vernacular.
I__________________ holding ______________(ID card type) with number __________(ID card number) hereby
declare that I have explained the contents of this declaration to the Proposed Insured/Applicant in
________________ language and that the Proposed Insured/Applicant has affixed his/her signature/thumb
impression after fully understanding the contents thereof.
________________________________ ___________________________
Signature/Thumb Impression of Proposed Insured/Applicant Witness Signature
Tata AIA Life Insurance Company Limited

.(IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower Parel, Mumbai – 400013
For more information, call our Helpline Numbers 1860-266- 9966 (local charges apply).
Unique Reference Number L&C/Misc/2014/Nov/238

Anxiety Depression Questionnaire

Uploaded by

Copyright:

Available Formats

Anxiety Depression Questionnaire

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Anxiety Depression Questionnaire

Uploaded by

Copyright:

Available Formats

Anxiety/Depression Questionnaire

Name Of Proposed Insured: ............................................................................................................................

Policy no.: ....................................................................................... Dated:................................................

2) Date of first occurrence of the medical condition? ................................................

3) Name of main doctor attended for the medical condition?

4) Was your condition related to any particular event?.....................................................................

7) Do you still receive treatment or suffer any symptoms? Yes No

8) What treatment have you received? If other, give details:

Past Medication: ..........................................................................................................................

Tata AIA Life Insurance Company Limited

12) Have you ever attempted or contemplated committing suicide? Yes No

Signature of Proposed insured:__ Date:

Signature of Applicant:__ Date:

Tata AIA Life Insurance Company Limited

You might also like