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1、中英人寿保险有限公司厦门分公司厦门湖滨中路9号交通银行大厦13层 20101001版式电话：0592-2273180 传真：0592-2273123团体保险被保险人健康告知书Health Statement for Group Insurance InsurantsA、被保险人资料：Information of Insurant:投保人/ Company：被保险人姓名/ Name：被保险人与员工的关系：配偶 子女The insured person and employee relations：Spouse child附属被保险人姓名：Name of the subsidiary insure
2、d：身份证号码：ID：性别/ Gender：年龄/Age：B、健康告知：Health Statement:1、被保险人身高 cm，体重 pound/kg，过去两年内体重是否增减超过5公斤？Height cm, Weight pound/kg; during the last two years, have you gained/lost weight for over 11bounds/5 kg?是Yes 否No2、过去两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？During the last two years, have you ever been suggested
3、to receive other kinds of physical examinations or treatments owing to some abnormal findings detected during your routine health examination? 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？During the most recent 6 months, have you ever taken pharmaceutical treatment, surgical operation or medicines owing
4、 to the cause of injury or sickness? If the answer is yes ,please give the reason.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 you currently suffering from ablepsia, deafmutism, masticatory dysfunction, defect of extremities, deformity or functional disturbance? 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
5、或用药？During the past five years, have you suffered from the following diseases and taken corresponding treatments and medicines?（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 (the systolic pressure is above 140mmHg or th
6、e diastolic pressure is above 90mmHg), angina pectoris, coronary occlusion, pachynsis of cardiac muscle, endocarditis, rheumatic heart disease, congenital heart disease, angioma of aorta, broaden of cardiac muscle, valvular heart disease (coarctation, prolapsus, defect, insufficiency or deformity),
7、overspeed of heart-beat or arrhythmia. （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。Cerebral apoplexy (cerebral hemorrhage, cerebral infarction), transient cerebral ischemia, encephaloma, angioma of cerebral arteries, ce
8、rebral arteriosclerosis, arteriovenous malformation, multiple sclerosis, myeleterosis, epilepsy, sweeny, myasthenia gravis, disturbance of intelligence (unapparent from the appearance), Parkinsons disease, insanity, cerebral palsy, cretinism, manic depression, hypochondria and motoneuron diseases. （
9、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。Chronic bronchitis, emphysema, bronchiectasis, pneumoconiosis, phthisis, chronic obstructive disease of lung, asthma, pulmonary abscess, pulmonary embolism, pleuritis and other respiratory diseases. （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）、
10、肝炎带原。Hepatitis, intrahepatic concretion, hepatocirrhosis, liver dysfunction (the examination result being different from the normal value) and hepatitis carrier. （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, nephropathy syndrome, kidney dysfunction, renal failure, uremia,
11、renal sac endoenzyme, urinary lithiasis, urinary tract deformity, bladder diseases, prostate diseases or other urogenital system diseases. （6）血管畸形、视网膜出血或剥离、视神经病变、眼底病变。Vessel deformity, retinal hemorrhage or decollement, optic nerve lesion, or eyeground lesion. （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
12、物。Cancer (malignancy), unproven tumour, polypus, hard lump, cyst or excrescence of the large intestine. （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, purple plague and other blood system diseases, blood donation prohibited. （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。Dia
13、betes, arthritis, acromegaly, pituitarygland hyperfunction or hypopituitarism, thyroid or parathyroid gland hyperfunction or hypopituitarism. （10）红斑性狼疮、胶原症或其它结缔组织疾病。Lupus erythematosus, collagen diseases or other desmosis diseases（11）艾滋病或艾滋病带原。AIDS or AIDS carrier（12）胸、颈、腰椎骨疾病或其它骨骼系统疾病。Chest, neck o
14、r lumbar vertebrae related diseases or other skeletal system diseases是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No是Yes 否No6、过去一年内是否曾因下列疾病，接受治疗、诊疗或用药？During the past one year, have you the following diseases and taken corresponding treatments and med
15、icines?（1）性病、酒精或药物滥用成瘾、各种眩晕症。Venereal disease, alcohol or drug addiction, megrims. （2）食道、胃、十二指肠溃疡或出血、溃疡性大肠炎、胰脏炎。Ulcer or hemorrhage of the gullet, stomach or duodena, ulcer related colitis or pancreatitis. （3）肝炎病毒带原、肝脓疡、肝脾肿大、黄疸。Hepatitis virus carrier, hepatic abscess, hepatosplenomegaly or icterus. （4）慢性支气管炎、气喘、肝脓疡、肺栓塞、肋膜炎。Chronic bronchitis, asthma, hepatic abscess, pulmonary embolism or pleurisy. （5）痛风、高血脂症、青光眼、白内障。Podagra, hyperlipemia, glaucoma or cataracta. （6）口腔白斑或纤维化或溃疡、不明皮肤色素淀、体重减
