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

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,haveyoueverbeensuggestedtoreceiveotherkindsofphysicalexaminationsortreatmentsowingtosomeabnormalfindingsdetectedduringyourroutinehealthexamination?□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？Areyoucurrentlysufferingfromablepsia,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,rheumaticheartdisease,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,myastheniagravis,disturbanceofintelligence(unapparentfromtheappearance),Parkinson'sdisease,insanity,cerebralpalsy,cretinism,manicdepression,hypochondriaandmotoneurondiseases.③慢性支气管炎、肺气肿、支气管扩张症、尘肺症、肺结核、慢性阻塞性肺疾病、哮喘、肺脓肿、肺栓塞、胸膜炎及其他呼吸系统疾病。Chronicbronchitis,emphysema,bronchiectasis,pneumoconiosis,phthisis,chronicobstructivediseaseoflung,asthma,pulmonaryabscess,pulmonaryembolism,pleuritisandotherrespiratorydiseases.④肝炎、肝内结石、肝硬化、肝功能异常（肝功能检验结果异于检验标准的正常值）、肝炎带原。Hepatitis,intrahepaticconcretion,hepatocirrhosis,liverdysfunction(theexaminationresultbeingdifferentfromthenormalvalue)andhepatitiscarrier.⑤肾脏炎、肾病症候群、肾功能异常、肾衰竭、尿毒、肾囊胞、尿路结石、尿路畸形、膀胱疾病、前列腺疾病或其它泌尿生殖系统疾病。Nephritis,nephropathysyndrome,kidneydysfunction,renalfailure,uremia,renalsacendoenzyme,urinarylithiasis,urinarytractdeformity,bladderdiseases,prostatediseasesorotherurogenitalsystem□是Yes□否No□是Yes□否No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：[phone]传真：[phone]diseases.⑥血管畸形、视网膜出血或剥离、视神经病变、眼底病变。Vesseldeformity,retinalhemorrhageordecollement,opticnervelesion,oreyegroundlesion.⑦癌症（恶性肿瘤）、未经证实为良性或恶性之肿瘤、大肠息肉、硬块、囊肿、赘生物。Cancer(malignancy),unproventumour,polypus,hardlump,cystorexcrescenceofthelargeintestine.⑧血友病、白血病、各类贫血、紫斑症及其它各类的血液系统疾病，被建议不宜献血。Hemophilia,leukaemia,anemia,purpleplagueandotherbloodsystemdiseases,blooddonationprohibited.⑨糖尿病、类风性关节炎、肢端肥大症、脑下垂体机能亢进或低下、甲状脉或副甲状腺功能亢进或低下。Diabetes,arthritis,acromegaly,pituitaryglandhyperfunctionorhypopituitarism,thyroidorparathyroidglandhyperfunctionorhypopituitarism.⑩红斑性狼疮、胶原症或其它结缔组织疾病。艾滋病或艾滋病带原。胸、颈、腰椎骨疾病或骨骼系统疾病Lupuserythematosus,collagendiseasesorotherdesmosisdiseases;AIDSorAIDScarrier;chest,neckorlumbarvertebraerelateddiseasesorskeletalsystemdiseases.⑪性病、酒精或药物滥用成瘾、各种眩晕症。Venerealdisease,alcoholordrugaddiction,megrims.⑫食道、胃、十二指肠溃疡或出血、溃疡性大肠炎、胰脏炎。Ulcerorhemorrhageofthegullet,stomachorduodena,ulcerrelatedcolitisorpancreatitis.⑬肝炎病毒带原、肝脓疡、肝脾肿大、黄疸。Hepatitisviruscarrier,hepaticabscess,hepatosplenomegalyoricterus.⑭慢性支气管炎、气喘、肝脓疡、肺栓塞、肋膜炎。Chronicbronchitis,asthma,hepaticabscess,pulmonaryembolismorpleurisy.⑮痛风、高血脂症、青光眼、白内障。Podagra,hyperlipemia,glaucomaorcataracta.⑯口腔白斑或纤维化或溃疡、不明皮肤色素淀、体重减轻超过10%以上。Oralleukoplakia,fibrosisorulcer,skinpigmentation,lossofweightforover10%.⑰未经证实之良性或恶性肿瘤、心脏传导性疾病、心脏瓣膜缺损、气胸、大肠躁动症、泌尿道感染症、风湿症、四肢麻痹及浮肿、白血球增多症、椎间盘突出症、单核白血球增多症、B型肝炎带原、肺炎、胆结石、尿路结石、肝内结石、肝肿大、大肠息肉、骨盆腔炎、中耳炎、不明原因发烧超过二周、进行性肌萎缩、硬皮症、卵巢炎、输卵管炎、前列腺肥大或发炎、慢性胃炎、子宫颈糜烂、子宫脱出、疝气、脑挫伤、脑震荡。Unprovenbenignormalignanttumor,heart-conductivediseases,defectofheartvalve,pneumothorax,largeintestinedisorder,urinarytractinfection,rheumatism,quadriplegiaoredema,leukocytosis,protrusionofntervertebraldisc,increaseofmonocyte,B-typehepatitiscarrier,pneumonia,gallstone,urinarylithiasis,intrahepaticconcretion,hepatomegaly,polypusoflargeintestine,pelvicinfection,tympanitis,unknownfeverofoverweeks,progressivemuscularatrophy,scleroderma,ovaritis,salpingitis,prostatichypertrophyorprostatitis,chronicgastritis,cervicalerosion,uterineprolapse,herniae,braincontusionorcerebralconcussion.6、女性被保险人回答：Ifyouarefemale,pleaseanswerthefollowingquestions①目前是否患有乳腺炎、乳漏症、乳房或淋巴结肿大、肿块、疼痛、血性溢乳等感觉或异常发现？Areyoucurrentlysufferingfrommastitis,galactorrhea,breastlymphadenopath/tumour/painorhematiclactorrhea?□是Yes□否No②目前是否有子宫内膜异位症、阴道异常出血、子宫颈抹片检查异常？Areyoucur