健康新告知书-厦门大学人事处.docVIP

中英人寿保险有限公司 中英人寿保险有限公司福建分公司 福州市鼓楼区五四路136号中银大厦24层 电话：（86）0591 传真：（86）0591团体保险被保险人健康告知书 Health Statement for Group Insurance Insurants A、被保险人资料： Information of Insurant: 投保人/ Company： 被保险人姓名/ Name： 被保险人与员工的关系：□配偶 □子女 The insured person and employee relations：□Spouse □child 附属被保险人姓名： Name of the subsidiary insured： 身份证号码： ID： 性别/ Gender： 年龄/Age： B、健康告知： Health Statement: 1、被保险人身高 cm，体重 pound/kg，过去两年内体重是否增减超过5公斤？ Height cm, Weight pound/kg; during the last two years, have you gained/lost weight for over 11bounds/5 kg? □是Yes □否No 2、过去两年内是否曾因接受健康检查有异常情形而被建议接受其他检查或治疗？ During the last two years, have you ever been suggested to receive other kinds of physical examinations or treatments owing to some abnormal findings detected during your routine health examination? □是Yes □否No 3、最近六个月是否曾因受伤或生病接受药物治疗、外科手术或服用药物？ During the most recent 6 months, have you ever taken pharmaceutical treatment, surgical operation or medicines owing to the cause of injury or sickness? If the answer is yes ,please give the reason. □是Yes □否No 4、目前身体是否有失明、聋哑及言语、咀嚼障碍、四肢缺损、畸形及机能障碍？ Are you currently suffering from ablepsia, deafmutism, masticatory dysfunction, defect of extremities, deformity or functional disturbance? □是Yes □否No 5、过去五年内，是否曾患有下列疾病，而接受治疗、诊疗或用药？ During the past five years, have you suffered from the following diseases and taken corresponding treatments and medicines? （1）高血压（指收缩压140mmHg或舒张压90mmHg以上）、狭心症、心肌梗塞、心肌肥厚、心内膜炎、风湿性心脏病、先天性心脏病、主动脉血管瘤、心肌扩大、心脏瓣膜疾病（狭窄、脱垂、缺损、闭锁不全、畸形）、心博过速或过缓性心律不整。 Hypertension (the systolic pressure is above 140mmHg or the diastolic pressure is above 90mmHg), angina pectoris, coronary occlusion, pachynsis of cardiac muscle, endocarditis, rheumatic heart disease, congenital heart disease, angioma of aorta, broaden of cardiac muscle, valvular heart disease (coarctation, prolapsus, defect, insufficiency or deformity), overspeed of heart-beat or arrhythmia. （2）脑中风（脑出血、脑梗塞）、短暂性脑缺血、脑瘤、脑动脉血管瘤、脑动脉硬化症、脑动静脉畸形、多发性硬化症、脊髓病变、癫痫、肌肉