1、.PAGE ：.；中英人壽保險福建分公司福州市鼓樓區(qū)五四路號中銀大廈24層：860591 87849888 ：860591 87840609團(tuán)體保險被保險人安康告知書Health Statement for Group Insurance InsurantsA、被保險人資料：Information of Insurant:投保人/ Company：被保險人姓名/ Name：被保險人與員工的關(guān)系：配偶 子女The insured person and employee relations：Spouse child附屬被保險人姓名：Name of the subsidiary insured：身份

2、證號碼：ID：性別/ Gender：年齡/Age：B、安康告知：Health Statement:1、被保險人身高 cm，體重 pound/kg，過去兩年內(nèi)體重能否增減超越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No2、過去兩年內(nèi)能否曾因接受安康檢查有異常情形而被建議接受其他檢查或治療？During the last two years, have you ever been suggested to r

3、eceive other kinds of physical examinations or treatments owing to some abnormal findings detected during your routine health examination? 是Yes 否No3、最近六個月能否曾因受傷或生病接受藥物治療、外科手術(shù)或服用藥物？During the most recent 6 months, have you ever taken pharmaceutical treatment, surgical operation or medicines owing to

4、the cause of injury or sickness? If the answer is yes ,please give the reason.是Yes 否No4、目前身體能否有失明、聾啞及言語、咀嚼妨礙、四肢缺損、畸形及機(jī)能妨礙？Are you currently suffering from ablepsia, deafmutism, masticatory dysfunction, defect of extremities, deformity or functional disturbance? 是Yes 否No5、過去五年內(nèi)，能否曾患有以下疾病，而接受治療、診療或用藥？

5、During the past five years, have you suffered from the following diseases and taken corresponding treatments and medicines?1高血壓指收縮壓140mmHg或舒張壓90mmHg以上、狹心癥、心肌堵塞、心肌肥厚、心內(nèi)膜炎、風(fēng)濕性心臟病、先天性心臟病、自動脈血管瘤、心肌擴(kuò)展、心臟瓣膜疾病狹窄、脫垂、缺損、閉鎖不全、畸形、心博過速或過緩性心律不整。Hypertension (the systolic pressure is above 140mmHg or the diastoli

6、c 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

7、of heart-beat or arrhythmia. 2腦中風(fēng)腦出血、腦堵塞、短暫性腦缺血、腦瘤、腦動脈血管瘤、腦動脈硬化癥、腦動靜脈畸形、多發(fā)性硬化癥、脊髓病變、癲癇、肌肉萎縮癥、重癥肌無力、智能妨礙外表無法明顯判別者、帕金森氏癥、精神病、腦性麻木、癡呆癥、躁郁癥、憂郁癥、運(yùn)動神經(jīng)原疾病。Cerebral apoplexy (cerebral hemorrhage, cerebral infarction), transient cerebral ischemia, encephaloma, angioma of cerebral arteries, cerebral arteriosc

8、lerosis, arteriovenous malformation, multiple sclerosis, myeleterosis, epilepsy, sweeny, myasthenia gravis, disturbance of intelligence (unapparent from the appearance), Parkinsons disease, insanity, cerebral palsy, cretinism, manic depression, hypochondria and motoneuron diseases. 3慢性支氣管炎、肺氣腫、支氣管擴(kuò)張

9、癥、塵肺癥、肺結(jié)核、慢性阻塞性肺疾病、哮喘、肺膿腫、肺栓塞、胸膜炎及其他呼吸系統(tǒng)疾病。Chronic bronchitis, emphysema, bronchiectasis, pneumoconiosis, phthisis, chronic obstructive disease of lung, asthma, pulmonary abscess, pulmonary embolism, pleuritis and other respiratory diseases. 4肝炎、肝內(nèi)結(jié)石、肝硬化、肝功能異常肝功能檢驗(yàn)結(jié)果異于檢驗(yàn)規(guī)范的正常值、肝炎帶原。Hepatitis, intrah

10、epatic concretion, hepatocirrhosis, liver dysfunction (the examination result being different from the normal value) and hepatitis carrier. 5腎臟炎、腎病癥候群、腎功能異常、腎衰竭、尿毒、腎囊胞、尿路結(jié)石、尿路畸形、膀胱疾病、前列腺疾病或其它泌尿生殖系統(tǒng)疾病。Nephritis, nephropathy syndrome, kidney dysfunction, renal failure, uremia, renal sac endoenzyme, ur

11、inary lithiasis, urinary tract deformity, bladder diseases, prostate diseases or other urogenital system diseases. 6血管畸形、視網(wǎng)膜出血或剝離、視神經(jīng)病變、眼底病變。Vessel deformity, retinal hemorrhage or decollement, optic nerve lesion, or eyeground lesion. 7癌癥惡性腫瘤、未經(jīng)證明為良性或惡性之腫瘤、大腸息肉、硬塊、囊腫、贅生物。Cancer (malignancy), unprove

12、n tumour, polypus, hard lump, cyst or excrescence of the large intestine. 8血友病、白血病、各類貧血、紫斑癥及其它各類的血液系統(tǒng)疾病，被建議不宜獻(xiàn)血。Hemophilia, leukaemia, anemia, purple plague and other blood system diseases, blood donation prohibited. 9糖尿病、類風(fēng)性關(guān)節(jié)炎、肢端肥大癥、腦下垂體機(jī)能亢進(jìn)或低下、甲狀脈或副甲狀腺功能亢進(jìn)或低下。Diabetes, arthritis, acromegaly, pitu

13、itarygland hyperfunction or hypopituitarism, thyroid or parathyroid gland hyperfunction or hypopituitarism. 10紅斑性狼瘡、膠原癥或其它結(jié)締組織疾病。Lupus erythematosus, collagen diseases or other desmosis diseases11艾滋病或艾滋病帶原。AIDS or AIDS carrier12胸、頸、腰椎骨疾病或其它骨骼系統(tǒng)疾病。Chest, neck or lumbar vertebrae related diseases or o

14、ther skeletal system diseases是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No6、過去一年內(nèi)能否曾因以下疾病，接受治療、診療或用藥？During the past one year, have you the following diseases and taken corresponding treatments and medicines?1性病、酒精或藥物濫用成癮、各種眩暈癥。Venereal dise

15、ase, alcohol or drug addiction, megrims. 2食道、胃、十二指腸潰瘍或出血、潰瘍性大腸炎、胰臟炎。Ulcer or hemorrhage of the gullet, stomach or duodena, ulcer related colitis or pancreatitis. 3肝炎病毒帶原、肝膿瘍、肝脾腫大、黃疸。Hepatitis virus carrier, hepatic abscess, hepatosplenomegaly or icterus. 4慢性支氣管炎、氣喘、肝膿瘍、肺栓塞、肋膜炎。Chronic bronchitis, as

16、thma, hepatic abscess, pulmonary embolism or pleurisy. 5痛風(fēng)、高血脂癥、青光眼、白內(nèi)障。Podagra, hyperlipemia, glaucoma or cataracta. 6口腔白斑或纖維化或潰瘍、不明皮膚色素淀、體重減輕超越10%以上。Oral leukoplakia, fibrosis or ulcer, skin pigmentation, loss of weight for over 10%. 7未經(jīng)證明之良性或惡性腫瘤、心臟傳導(dǎo)性疾病、心臟瓣膜缺損、氣胸、大腸躁動癥、泌尿道感染癥、風(fēng)濕癥、四肢麻木及浮腫、白血球增多癥、

17、椎間盤突出癥、單核白血球增多癥、B型肝炎帶原、肺炎、膽結(jié)石、尿路結(jié)石、肝內(nèi)結(jié)石、肝腫大、大腸息肉、骨盆腔炎、中耳炎、不明緣由發(fā)燒超越二周、進(jìn)展性肌萎縮、硬皮癥、卵巢炎、輸卵管炎、前列腺肥大或發(fā)炎、慢性胃炎、子宮頸糜爛、子宮脫出、疝氣、腦挫傷、腦震蕩。Unproven benign or malignant tumor, heart-conductive diseases, defect of heart valve, pneumothorax, large intestine disorder, urinary tract infection, rheumatism, quadriplegia

18、 or edema, leukocytosis, protrusion of ntervertebral disc, increase of monocyte, B-type hepatitis carrier, pneumonia, gallstone, urinary lithiasis, intrahepatic concretion, hepatomegaly, polypus of large intestine, pelvic infection, tympanitis, unknown fever of over weeks, progressive muscular atrop

19、hy, scleroderma, ovaritis, salpingitis, prostatic hypertrophy or prostatitis, chronic gastritis, cervical erosion, uterine prolapse, herniae, brain contusion or cerebral concussion. 是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No7、父母、兄弟姐妹、子女中能否患有高血壓、心臟病、中風(fēng)、糖尿病、甲狀腺疾病、腎臟疾病、惡性腫瘤、精神病或其它

20、遺傳性疾病？Are your parents, brothers, sisters or children suffering from hypertension, heart diseases, apoplexy, diabetes, thyroid diseases, kidney diseases, malignant tumor, insanity or other hereditary diseases? If the answer is yes. Please give details about whos the disease sufferer and the disease

21、history.8、女性被保險人回答：If you are female, please answer the following questions1目前能否患有乳腺炎、乳漏癥、乳房或淋巴結(jié)腫大、腫塊、疼痛、血性溢乳等覺得或異常發(fā)現(xiàn)？Are you currently suffering from mastitis, galactorrhea, breast lymphadenopath/tumour/pain or hematic lactorrhea? 2目前能否有子宮內(nèi)膜異位癥、陰道異常出血、子宮頸抹片檢查異常？Are you currently suffering from endo

22、metriosis, abnormal vagina hemorrhage or other abnormal findings in the papanicolaou test? 3過去能否曾因乳房、子宮內(nèi)膜異位、卵巢等疾病而接受診斷、治療或用藥？During the past years, have you suffered from breast, endometriosis or ovarium related diseases and taken corresponding treatments and medicines? 4目前能否已懷孕？如是，曾經(jīng) 周女性被保險人回答Are y

23、ou currently pregnant? If yes, please indicate the number of weeks _(for female insurants)是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No以上各項(xiàng)回答為“是，請?jiān)诖藱谧⒚髟敿?xì)的傷病稱號、診治日期、醫(yī)院稱號、治療情形及目前情況If your answer is Yes, please indicate here the name of disease, date of treatment, name of hospital, treatment detail youre yo

24、ur current status.The name of disease：Date of treatment：Name of hospital：Treatment conditions：Your current status：C、被保險人聲明及授權(quán)：Statement and authorization of the insurant: 被保險人聲明及授權(quán) Statement and authorization of the insurant 1、本安康告知書作為保險人簽發(fā)保險合同之根據(jù)，本人確認(rèn)上述內(nèi)容真實(shí)無誤，如有隱匿、脫漏或不實(shí)之陳說，保險公司可根據(jù)第三十六條解除本人保險合同；This health statement is regarded as a reference to the insurer for signing and issuing the insurance contract. I declare that all the above information is true and a