MEDICard Philippines, Inc.

Registration

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Username:
MEDICard ID:
Email:
Password:
Verify Password:
First Name:
Last Name:
Middle Name:
Address:
Contact No:
Birthday:
Gender:
Civil Status:
Have you ever treated for or ever had any known indication of disorder of eyes, ears, nose, or throat? If Yes, give details:
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Dizziness, fainting, convulsions, headache, speech defect, paralysis or stroke, mental or nervous disorder? If Yes, give details:
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Shortness of breath, persistent hoarseness or cough, blood-spitting bronchitis, pleurisy, asthma, emphysema, tuberculosis or chronic respiratory disorder? If Yes, give details:
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Chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack or any other disorder of the heart or blood vessels? If Yes, give details:
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Jaundice intestinal bleeding, ulcer, hernia, appendicitis, diverticulitis colitis, hemorrhoids, recurrent indigestion, or other disorder of the stomach intestine, liver or gallbladder? If Yes, give details:
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Sugar, albumin, blood or pus in urine, venereal disease, stone or other disorder of kidney, bladder, prostate or reproductive organs? If Yes, give details:
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Diabetes thyroid or other endocrine disorder? If Yes, give details:
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Deformity, lameness or amputation? If Yes, give details:
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Neuritis, sciatica, rheumatism, arthritis, gout, or disorder of the muscles or bones, such as spine, back or joints? If Yes, give details:
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Disorder of skin, lymph glands, cysts, tumor or cancer? If Yes, give details:
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Allergies, anemia or other disorder of the blood? If Yes, give details:
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Excessive use of alcohol, tobacco or any habit-forming drug? If Yes, give details:
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Are you now under observation or taking treatment? If Yes, give details:
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Do you smoke cigarette? If so, how many sticks a day?:
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Other than above, have you had any physical disorder or any known indication thereof? If Yes, give details:
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Had electrocardiogram, x-ray, other diagnostic test? If Yes, give details:
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Had a medical examination, consultations, illness, injury, surgery? If Yes, give details:
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Been a patient in a hospital, clinic, sanitarium, or other medical facility? If Yes, give details:
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Been advised to have a diagnostic test, hospitalization, or surgery which was not completed? If Yes, give details:
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Have you ever had military service deferment, rejection or discharge because of physical or mental condition? If Yes, give details:
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Have you ever applied for or receive a pension, payment, or benefit due to injury, sickness or disability? If Yes, give details:
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Have you a parent, brother, sister who died of or had high blood pressure, tubercolosis, diabetes, cancer, heart or kidney disease, or mental illness? If Yes, give details:
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FOR FEMALES ONLY: Have you ever had any abnormal menstruation, pregnancy, childbirth or disorder of the female organs or breast? If Yes, give details:
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FOR FEMALES ONLY: Are you now pregnant? If yes, how many months?:
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FOR FEMALES ONLY: Are you taking contraceptives pills? If Yes, give details:
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Have you ever been rejected or terminated for medical insurance including MEDICard program, or have been offered insurance at a higher (rated-up) premium? If Yes, give details:
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