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1、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）059187849888传真：（86）059187840609团体保险被保险人健康告知书HealthStatementforGroupInsuranceInsurants被保险人资料：InformationofInsurant:投保人名称/Company：被保险人姓名/Name：证件类型/CertificateType□ID□Passport□Other证件号码/CertificateNo.健康告知：HealthStatement:1、被保险人身
2、高cm，体重kg，过去两年内体重是否增减超过5公斤？Heightcm,Weightkg;duringthelasttwoyears,haveyougained/lostweightforover5kg?□是Yes□否No2、过去2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？Duringthelasttwoyears,haveyoueverbeensuggestedtoreceiveotherkindsofphysicalexaminationsortreatmentsowingtosomeabnormalfin
3、dingsdetectedduringyourroutinehealthexamination?□是Yes□否No3、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？Duringthemostrecent6months,haveyouevertakenpharmaceuticaltreatment,surgicaloperationormedicinesowingtothecauseofinjuryorsickness?□是Yes□否No4、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
4、youcurrentlysufferingfromablepsia,deafmutism,masticatorydysfunction,defectofextremities,deformityorfunctionaldisturbance?□是Yes□否No5、过去五年内，是否曾患有下列疾病，而接受治疗、诊疗或用药？Duringthepastfiveyears,haveyousufferedfromthefollowingdiseasesandtakencorrespondingtreatmentsandmedicines?①
5、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(thesystolicpressureisabove140mmHgorthediastolicpressureisabove90mmHg),anginapectoris,coronaryocclusion,pachynsisofcardiacmuscle,endocarditis,r
6、heumaticheartdisease,congenitalheartdisease,angiomaofaorta,broadenofcardiacmuscle,valvularheartdisease(coarctation,prolapsus,defect,insufficiencyordeformity),overspeedofheart-beatorarrhythmia.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、肌肉萎缩症、重症肌无力、智能障
7、碍（外表无法明显判断者）、帕金森氏症、精神病、脑性麻痹、痴呆症、躁郁症、忧郁症、运动神经原疾病。Cerebralapoplexy(cerebralhemorrhage,cerebralinfarction),transientcerebralischemia,encephaloma,angiomaofcerebralarteries,cerebralarteriosclerosis,arteriovenousmalformation,multiplesclerosis,myeleterosis,epilepsy,sweeny,m
8、yastheniagravis,disturbanceofintelligence(unapparentfromtheappearance),Parkinson'sdisease,insanity,cerebralpalsy,cretinism,manicdep
