Health Insurance Questionnaire Template

July 1, 2011

A Health insurance questionnaire template is a ready too use document for framing a questionnaire to assess the physical condition of an individual for insurance coverage. The template includes the personal and medical history of an individual.

Sample Health Insurance Questionnaire Template

Name_______
Age_____
Sex_______
Contact Details____________
(This section asks for personal and contact details of person.)
Blood group________
Weight________
Height_______
(Here the health information will appear.)
Questionnaire
(This is the main section of template for questions.)
1. Name the type of insurance cover you need?
A. Option 1.
B. Option 2.
C. Option 3.
D. Option 4.
2. Whom the claim should be sent to?
A. Option 1.
B. Option 2.
C. Option 3.
D. Option 4.
3. Do you have any chronic dieses problem, if yes then name it?
A. Option 1.
B. Option 2.
C. Option 3.
D. Option 4.
4. Have you undergone any medical surgery in the last 1 year, if yes then please provide details? ____________________

Download Health Insurance Questionnaire Template in Word Format

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