depression questionnaire

DEPRESSION QUESTIONNAIRE
(To be completed by the medical attendant)
Policy details
Policy no.
ID no.
Name of insured
1. When did the symptoms of the applicant’s condition first occur? State month, year and duration
2. What were the symptoms?
(a) Physical e.g. loss of weight, loss of appetite, fast pulse, stomach trouble
(b) Mental e.g. insomnia, anxiety, worry, depression
3. When did the symptoms last occur?
Y
Y
Y
Y
M
M
D
D
4. In your opinion what caused the condition and relapses?
5. What was the final diagnosis made by you?
6. What treatment/type of medication are they currently taking? State dosage of medication and type of other treatment(s) if applicable
7. What treatment/medication did they receive in the past? State dosage and type of medication and type of other treatment(s) if
applicable
8. For how long has the applicant been on treatment/medication?
9. Have they ever been absent from work as a result of their condition?
Y
N
Y
N
Y
N
Y
N
If yes, for how long?
10. Have they ever been hospitalised?
If yes, give details
11. Is there anyone in the applicant’s family who suffers from a nervous or mental condition?
12. Has the applicant ever attempted suicide?
If yes, give details
DEPRESSION QUESTIONNAIRE | 120115 | 1 of 2
If yes, give details
13. Has the applicant undergone any special examinations, tests or investigations?
Y
N
Y
N
D
D
If yes, give details
14. Are they completely cured and have they fully recovered?
Provide details
15. Give the name(s) and address(es) of the doctor(s) and other specialists who have treated the applicant
Notice to medical attendants
Hollard Life will reimburse all medical accounts issued according to the insurance billing code.
General practitioner - insurance billing code A1403
Practice no.
Tel no.
Fax no.
Full name
E-mail address
Postal address
Please send your account to either 086 693 7567 or [email protected]
Declaration by medical attendant
Signature
(medical attendant)
Date
Y
Y
Y
Y
M
M
DEPRESSION QUESTIONNAIRE | 120115 | 2 of 2
I declare that the statements above are true and complete.