Pancreatitis (1)

(1)

Hypertension

Other

Other

Inguinal Hernia

Digestive Haemorrhage (1)

Other

Cardiac Insufficiency (1)

Infarction or Angina Pectoris (1)

Arrhythmias or Blocks / Pacemaker

Bronchiectasis (1)

ibrosis (1)

Pleurisy (1)

Haemorrhoids (1)

Thrombophllebitis (1)

Endocarditis (1)

Varicose Veins

(1)

Asthma (1)

Oesophageal Diseases (1)

Hiatus Hernia

Chronic Gastritis

B - ?

C -

:

:

:

Se sim, indique qual:

City:

Height (m, cm)

Do you drink alcohol? What do you drink?

How long have you smoked (years)? Do you smoke? Yes No

Yes

A - ? Yes

No

Weight (Kg) Blood Pressure

Degree of Kinship: Holder Descendant Ascendant Other

: :

o the Insured or person taking out the insurance policy, which

during the contract period, such situations will release the Insurer from any obligation to p

IBAN:

:

Pág. 1 de 3

Yes

Yes

Pericarditis (1)

Valve Diseases (1)

(1)

Chronic Bronchitis (1)

Emphysema (1)

Pulmonary Tuberculosis (1)

Diverticulosis

Intestinal Polyps (1)

Yes No

Sex:

F

:

M

(1)

Haemodialysis

l

No

(1)

K

Tract Diseases (1)

D -

(1)

Hepatitis B, C, D or E (1)

E - Yes

Other

:

Prostate Disease (1)

Other

m x min

If yes, indicate daily consumption?

If yes, indicate the number of cigarettes per day?

(1) (1)

(1)

(1)

(1)

(1)

(1)

(1)

(1)

(1)

(1)

(1)

T (1)

(1)

(1)

(1)

(1)

(1)

F - ?

P -

(1)

I

-

J -

N -

O -

M -

L -

K -

:

:

:

:

:

:

:

(cont)

(1)Multiple M eloma (1)

(1)

No

G -

No

No

No

No

(1)

No

(1)

(2)

O

O

:

(3) :

(1)

O

O

O

O

O

O

O

Recurring Tonsillitis and Adenoiditis

Impaired Hearing / Use of Hearing Aids

Others

O

A (1)

Pág. 2 de 3

Renal

O

Q - No

(1)

(1)

(1)

H

H - Nervous System Diseases?

No

o

No

No

No

(1)

(1)

No

:

Describe the situation:

/ /,

:data

:

:

:

Duration:

2. :

3. :

you have neurological s

Personal Background – Do you have or have you ever been diagnosed with any of the following diseases (cont)

1.

Individual Medical Questionnaire Pág. 3 de 3

Insured Broker: Banco Comercial Português, S.A.,open society (Millennium bcp) – Head Office: Praça D. João I, 28, 4000-295 Porto – Share Capital – Unique Registration and Tax nr. 501525882. Mediador de Seguros Ligado nº 207074605 – Registration Date: 26/06/2007. Authorisation for the brokerage of the life and non-life insurance sector of the Seguradores Ocidental - Companhia Portuguesa de Seguros de Vida, S.A., Ocidental - Companhia Portuguesa de Seguros S.A., and Médis - Companhia Portuguesa de Seguros de Saúde, S.A. and also with Ocidental - Sociedade Gestora de Fundos de Pensões, S.A. For information and further registration details, please consult: www.asf.com.pt. The Insurance Intermediary is not authorized to sign insurance contracts on behalf of the Insurer or receive any insurance premiums payable to the Insurer. The Insurance Intermediary does not assume liability regarding any risks covered by the insurance contract, which shall be fully assumed by the Insurer.Insurer: Ocidental – Companhia Portuguesa de Seguros, S.A. Public Limited Company with its head office in Av. Dr. Mário Soares (Tagus Park), Edifício 10, Piso 1, 2744−002 Porto Salvo, tax nr. 501836918 and registered with this same number in the Lisbon Trade Registry, with a share capital of €12.500.000,00.Médis: exclusive and registered brand of the products managed by Médis – Companhia Portuguesa de Seguros de Saúde, SA, insurance company, reinsurer and manager of the healthcare integrated system subjacent to the insurance through Policies issued by itself or by other insurance companies authorised by it to do so. Entity legally authorized for the conduct of the activity in the non-life insurance.