Mutuelle sans Questionnaire Medical


A person should have a medical insurance to cover the expenses in case he is hospitalized and has to undergo treatment. The person has to answer a set of questions regarding these insurance policies that might lead to a ban over claiming insurance or it may limit your safe guards.

The purpose of Mutuelle sans Questionnaire is to guard against the large refunds one would have to pay. This questionnaire should be comprehensible to the common people and should facilitate collection of the proper information. Such a sample questionnaire is compiled and given below.

Sample Mutuelle sans Questionnaire Medical

Name: ______________________

Age: ______

Sex: _________

Date: ____________

Please answer the following questions in brief.

1)   What is the nature of your disease or physical condition?

____________________________________________________________________________________________________

2)   Who is your supervising physician?

________________________________________________________________________________________________

3)   Have you consulted any other doctor or physician in relation to this problem?

_______________________________________________________________________________________________________

4)   Since how long are you undergoing this treatment?

___________________________________________________________________________________________________

5)   What are the prescribed medications you are taking at present?

_________________________________________________________________________________________________

6)   Have you undergone any tests like the X-ray, ECG, EEG, CT-SCAN, ultrasonography etc.?

____________________________________________________________________________________________________________________

7)   If yes, then specify which one.

_____________________________________________________________________________________________________________

8)   Please mention the date and place where the tests were done.

_____________________________________________________________________________________________________

9)   For how long have you been hospitalized?

______________________________________________________________________________________________________

10)               According to your doctor, how long do you need to stay in the hospital under supervision?

________________________________________________________________________________________________________________

11)               Would you be undergoing surgery in the near future?

_____________________________________________________________________________________________________________________

12)               Have you undergone surgery before this duration of your stay?

____________________________________________________________________________________________

13)               Do you suffer from any hormonal or immunological diseases?

_________________________________________________________________________________________________________

14)               Do you suffer from any heart condition like artery blockage, bradycardia and tachycardia, etc.?

____________________________________________________________________________________

Category: Medical Questionnaire

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