THYROID DISORDER QUESTIONNAIRE

(To be filled by the Attending Physician of the Life To Be Assured)

Name of Life To Be Assured: _______________________________________________________Proposal No.: ______________________

1. Diagnosis : Goitre Hypothyroid Hyperthyroid Thyroiditis Malignancy

2. Size and shape: Please tick whichever is applicable Uniform Nodular Unilateral Bilateral

3. Is there any evidence of local tenderness Yes No

4. Is there any evidence of Hard or Firm

Yes No

5. Is he / she now on any drug treatment? If so mention the drugs with dosage and frequency Yes No

6. Do you consider the disease as:

Static and controlled Yes No

Progressive and uncontrolled Yes No

7. Ever had or been advised surgery or been hospitalized Yes No

If yes, please provide and attach all details pertaining to surgery and medication prescribed for this condition.

___________________________________________________________________________________________________________

8. Date of last visit to Doctor and laboratory investigations done. (Please provide all thyroid test results available of client)

9. Is there any evidence of complications like cardiac involvement, eye disease, personality changes etc. Yes No
If yes, please give details.

__________________________________________________________________________________________________________

I certify that the Life To Be Assured has put her/ his signature in my presence and I am satisfied with his/her identity.

Declaration in case of Life To Be Assured signs in Vernacular Language/ uses Thumb Impression:
I have read out and fully explained the contents of the questionnaire and he/she has understood the same. I have truthfully recorded the
replies given by the Life to be Assured and that the Life to be Assured has affixed the signature/thumb impression above after fully
understanding the contents thereof.

Signature and seal of Physician Signature /Thumb impression of Life To Be Assured

Physician’s name:

Date & Place:

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