健康告知书中英.docVIP

团体被保险人告知声明书 Health Declaration 投保团体：Insurance Applicant: 投保单号：Application Form No: 姓名： Full Name 性别Gender： □男Male □女Female 出生日期： 年 月 日 Date of Birth(YYYY/MM/DD) 年龄： 周岁 Age: 证件类型ID Type: □身份证ID Card □护照Passport □其它Others:_______ 证件号码ID No. 国籍Nationality: 职业Occupation: 职务Position: 个人年收入约Annual Income: 万元(Ten Thousand RMB) 身高Height: 厘米cm 体重Weight： 公斤kg 当地社会医疗保险参保人Covered by Local Sociomedical Insurance:□是Yes□否No 当地社会医疗生育保险参保人Covered by Local Social Maternity Insurance:□是Yes□否No 健康告知Health Declaration 若被保险人为未成年人，则请被保险人的父母代为回答。If the insured is below 18 years old, the blank should be filled in by his/her parents. 是 Yes 否 No 1.您目前是否能正常从事全职工作？Are you currently active at work on a full-time basis? □ □ 2. 您是否曾/正患有下列症状、疾病或残疾：Have you ever suffered/Are you currently suffering from the following symptoms,diseases and/or disabilities: （1）癌症、肿瘤、肿块、囊肿、息肉、淋巴结肿大、消瘦（体重一年内下降超过5公斤,不包括健身或减肥原因）？Cancer, tumor, lump, cyst, polyp, lymph node enlargement, weight loss (more than 5kg in one year, not caused by exercise and/or obesity control) □ □ （2）咳嗽或咯痰（一年中超过三个月）、咯血、呼吸困难、气胸、胸腔积液、哮喘、支气管扩张、慢性支气管炎、肺气肿、肺结核等呼吸系统疾病？Respiratory system disorder: cough or expectoration (more than 3 months in a year), emptysis, dyspnoea, pneumothorax, pleural effusion, asthma, bronchiectasis, chronic bronchitis, emphysema, lung tuberculosis, etc? □ □ （3）心慌、胸闷、胸痛、心律失常、心绞痛、心肌炎、心肌病、先天性心脏病、风湿性心脏病、冠心病、高血压、高血脂、动脉瘤等心脏血管疾病？Cardiovascular disorder: Palpitation, chest distress, chest pain, arrhythmia, angina, myocarditis, cardiomyopathy, congenital heart disease, rheumatic heart disease, coronary artery disease, hypertension, hyperlipidemia, aneurysm, etc? □ □ （4）反复腹痛或腹泻、呕血、便血、黄疸、吞咽困难、肝脾肿大、胃或十二指肠溃疡、慢性或溃疡性结肠炎、肝炎、肝炎病毒携带、肝硬化、脂肪肝、胆囊炎、肝胆结石、胰腺炎、痔疮、疝气、胃切除、肠切除、胰腺切除、肝切除、脾切除等消化系统疾病或残疾？Digestive system disorder and/or disabilities: frequent bellyache or diarrhea, hematemesis, hematochezia, jaundice, dysphagia, liver/spleen enlargement, gastric or duo