ValuCare Application Form112116
ValuCare Application Form112116
ValuCare Application Form112116
12. CITIZENSHIP 13. SEX 14. CIVIL STATUS 25. SPOUSE PHILHEALTH NO.
MALE FEMALE SINGLE WIDOWER
MARRIED LEGALLY SEPARATED
15. EMPLOYMENT STATUS 26. TELEPHONE NO.
EMPLOYED IN PRIVATE SELF-EMPLOYED OTHERS:__________ 27. CELLPHONE NO.
EMPLOYED IN GOVERNMENT OCW
28. FAX NO.
16. EMPLOYER / BUSINESS NAME
MEDICAL QUESTIONNAIRE
29. Were you a previous member of any HealthCare company? Yes No If YES, please give name of company:
______________________ When did your former membership begin_________________________ and end? ________________________
30. Have you been treated/examined/hospitalized while a member of this HealthCare company? Yes No If YES, please list location and
last exam of treatment.________________________________________________________________________________________________
31. Have you ever been rejected for medical insurance, including HealthCare plan, or been offered insurance at a higher (rated up) premium?
CASHIER UNDERWRITING
QUESTIONS NO. 36-38 MUST BE ANSWERED BY ALL FEMALE APPLICANTS OVER THE AGE OF 13
36. Date of you last menstrual period: 37. Are you pregnant? Yes No
MO DAY YEAR
38. History of menstrual flow: Regular Irregular Dysmenorrhea
39. Have you ever been hospitalized, diagnosed or treated for any of the following? If YES, please place a check in the box .
(FOR EVERY TIME CHECKED, PLEASE UNDERLINE THE ILLNESS & EXPLAIN IN NUMBER 41)
Alcoholism Heart attack or other hear trouble
Serious anemia or other blood diseases Heart murmur
Arthritis, gout or painful joints Hypertension or high blood pressure
Asthma/wheezing Hernia Surgically repaired? Yes No
Chronic cough, emphysema or other chronic lung diseases Immune Deficiency Syndromes, example AIDS
Back ache or back injury Ulcers of stomach or duodenum
Serious bodily injury or disability Venereal disease
Cancer, leukemia or tumors Persistent Indigestion or peptic symptoms
Convulsions, seizures or epilepsy Kidney condition, kidney stones
Diabetes mellitus Loss of urine control, bladder problems or difficulty in urination
Diarrhea or colitis (chronic), rectal bleeding or other rectal ailment Prostate problems
Ear problems or loss of hearing Liver conditions Cirrhosis Jaundice Hepatitis
Tubes now present in ear for otitis media Paralysis/Strokes
Eye condition (cataract, iritis, etc.) Serious skin disease, melanoma, psoriasis
Glaucoma Female organ abnormality
Gall bladder stones Surgically removed? Yes No Irregular vaginal bleeding
Goiter or thyroid condition Mental/emotional disorders
Hay fever or allergies Psychiatric counseling
Currently on allergy injections Drug addiction or abuse (Please specify)
Migraine headache
40. Have you ever been treated for any other condition not listed above?Yes No If Yes, Please describe:_______________________________
____________________________________________________________________________________________________________
41. If YES is checked for any condition in items 39 through 40, give details below:
HOSPITAL NAME DATE OF LAST
CONDITION ATTENDING PHYSICIAN PHYSICIAN’S ADDRESS
(If hospitalized) TREAMENT
________________________________________ ______________________________________________________________
PRINTED NAME AND SIGNATURE OF GA/CODE NO. SIGNATURE OF APPLICANT DATE
________________________________________ ______________________________________________________________
PRINTED NAME AND SIGNATURE OF DA/CODE NO. PRINTED NAME AND SIGNATURE OF PRINCIPAL DATE