Back & Neck Questionnaire (to be filled in by the physician / treating doctor)
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Name of Life to be insured:
___________________________________
sse^v C³jzÀ sN¿s¸tS­p¶ BfpsS t]cv
Date of Birth:
Policy/Application Number:
P\\ XobXn:
1.
2.
3.
t]mfnkn /At]£m \¼À:
Please state the precise diagnosis, or nature of the disorder e.g. simple back strain, degenerative disk disease,
herniated disk, lumbago, sciatica, spondylosis, spondyloarthropathy, whiplash, etc.:
IrXyamb Ubtámknkv Asæn tcmK¯nsâ kz`mhw Zbhmbn {]kvXmhn¡pI. DZm. sNdnb ]pdw thZ\,
UoP\sdbvänhv UnkvIv Unkokv, slÀ\nsbbvänUv UnkvIv, epw_mtKm, kvInbmänI, kvt]m¬Untemknkv,
kvt]m¬UntemBÀt{¯m]Xn, hn]vemjv XpS§nbh
When was the condition diagnosed or when did you first experience symptoms?
F¶mWv Cu AhØbpsS tcmK\nÀ®bw \S¯nbXv AsænÂ, F¶mWv \n§Ä¡v Cu
tcmKe£Ww BZyambn A\p`hs¸«Xv?
/ /
What was the underlying cause (e.g. accident, degeneration, recreational or sporting injury etc.)?
CXnsâ A´Àeo\amb ImcWw F´mWv (DZm. A]ISw, UoP\tdj³, hnt\mZ¯n\nSbntetbm, AsænÂ
kvt]mSvkn\nSbntetbm ]cn¡v XpS§nbh)?
4.
Please advise which part of your back is or was affected, e.g. cervical spine (neck), thoracic spine (upper
middle) or lumbar spine (lower) and describe your symptoms including details of any radiation down either the
arms or legs:
\n§fpsS ]pd¯nsâ GXp`mKamWv _m[n¡s¸«Xv, DZm. skÀÆn¡Â kvss]³ (Igp¯v), sXmdmkn¡v kvss]³
(apIÄþa[yw), Asæn ew_mÀ kvss]³ (Iogv)? \n§fpsS tcmKe£W§Ä, ssIImepIfnte¡v Ah hnIncWw
sN¿p¶XpÄs¸sSbpÅ, hnhcn¡pI:
5.
a)
Are symptoms ongoing?
 Yes
 No
tcmKe£W§Ä XpSÀ¶p sIm­ncn¡pIbmtWm?
AsX
AÃ
If yes, are the symptoms decreasing, remaining stable or worsening in severity?
D­v F¦nÂ, e£W§Ä IpdbpIbmtWm, DÅXvt]mse XpScpIbmtWm, Asæn ImTn\yw IqSnhcnIbmtWm?
b)
When did you last experience symptoms?
/ /
tcmKe£W§Ä Ahkm\ambn \n§Ä A\p`hn¨Xv Ft¸mgmWv?
Please also advise how often or how many times you have ever experienced symptoms and how long
the symptoms have persisted on these occasions?
\n§Ä Ft¸msgms¡bmWv, Asæn F{X{]mhiyamWv, tcmKe£Ww A\p`hn¨Xv F¶pw, C§ns\bpÅ
Hmtcm Ahkc¯nepw, tcmKw F{X t\cw \o­p\n¶p F¶pw Zbhmbn hnhcn¡pI.
c)
6.
Have your daily activities ever been affected or restricted in any way?
\n§fpsS \nXyhr¯nIÄ Ft¸msg¦nepw, GsX¦nepw hn[¯n _m[n¡s¸SpItbm,
Asæn ]cnanXs¸SpItbm sN¿s¸«n«pt­m?
If yes, please provide details:
D­v F¦nÂ, Zbhmbn AXnsâ hnhc§Ä \ÂIpI:
7.
Please provide details of any medication taken for this condition:
Cu tcmKmhØbv¡v \n§Ä D]tbmKn¨n«pÅ acp¶pIfpsS hnhc§Ä \ÂIpI:
Name of medication
acp¶nsâ t]cv
8.
Name of practitioner or clinic
{]mIv«ojWdptStbm, AsænÂ
Ivfn\n¡nsâtbm, t]cv
Address
taÂhnemkw
Have you ever had any tests or investigations carried out in connection with this
condition, e.g. x-ray, MRI, CT scan or nerve conduction studies?
\n§fpsS Cu tcmKmhØbpambn _Ôs¸«v \n§fn Fs´¦nepw sStÌm,
Asæn tcmK]cntim[\tbm \S¯s¸«n«pt­m? DZm. knSn kvIm³, FwBÀsF
Asæn s\ÀÆv I­£³ ]T\w XpS§nbh?
If yes, please provide details including dates, procedures, locations and results:
D­v F¦nÂ, XobXnIÄ, \S]Sn{Ia§Ä, Øew, ^e§Ä XpS§nbh AS¡w,
hniZmwi§Ä \ÂIpI:
Name of test or
investigation
sSÌnsâtbm,
AsænÂ
sshZy]cntim[
\bptStbm, t]cv
10.
Frequency
{^oIz³kn
 No
AÃ
Date last taken
Ahkm\w FSp¯
XobXn
Please provide details of any other treatment that you have had for this condition, e.g. surgery, treatment by
a physiotherapist, chiropractor, osteopath, massage therapist, acupuncturist etc.:
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^nkntbmsXdm¸nkväv, Nntdm{]mIvsSmÀ, HmknHm]¯v, sakmPv sXdm¸nÌv, FIyp]MvNdnÌv XpS§nbhcpsS NnInÕ XpS§nh:
Type of treatment
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9.
Dose
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 Yes
AsX
Location
Øew
Date
XobXn
Date of last consult
Ahkm\ambn
I¬kÄ«v sNbvX
XobXn
 Yes
AsX
 No
AÃ
Results
^e§Ä
Have you ever been admitted to hospital for this condition?
 Yes
Cu tcmKmhØbv¡mbn \n§Ä Ft¸msg¦nepw Bip]{Xnbn {]thin¡s¸«n«pt­m?
AsX
If yes, please provide details including dates, procedures, locations and results:
D­v F¦nÂ, XobXnIÄ, \S]Sn{Ia§Ä, Øew, ^e§Ä XpS§nbh AS¡w, hniZmwi§Ä \ÂIpI:
 No
AÃ
 Yes
AsX
 No
AÃ
11.
Has any future treatment or investigation been discussed or contemplated?
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NÀ¨sN¿s¸SpItbm, Asæn BtemNn¡pItbm sNbvXn«pt­m?
If yes, please provide details:
D­v F¦nÂ, Zbhmbn AXnsâ hnhc§Ä \ÂIpI:
12.
Please provide the name and address of the doctors and/or specialists you see in relation to this condition:
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DÅ hnhc§Ä \ÂIpI
Name of doctor, hospital or clinic
tUmIvSdpsS, Bip]{Xn AsænÂ
Ivfn\n¡nsâ t]cv
Address
taÂhnemkw
Dates
XobXn
13.
Have you ever taken time off work with this condition?
 Yes
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AsX
If yes, please provide details including dates and durations:
D­v F¦nÂ, hn«p\n¶ XobXnIfpw Ah[nbpsS ssZÀLyhpw DÄs¸sSbpÅ FÃmhnhc§fpw \ÂIpI
 No
AÃ
14.
Have your working duties ever been affected or restricted in any way, e.g. restricted
ability to drive, lift, carry objects, bend or sit for prolonged periods?
\n§fpsS sXmgn IÀ¯hy§Ä Ft¸msg¦nepw _m[n¡s¸SpItbm, ]cnanXs¸SpItbm
sNbvXn«pt­m? DZm. h­ntbmSn¡m\pÅ Ignhv IpdbpI, km[\§Ä hln¡m³
IgnbmXmhpI, IqSpXÂ t\cw Ip\nbmt\m Ccn¡mt\m BhmXmIpI
If yes, please provide details including dates and durations
D­v F¦nÂ, hn«p\n¶ XobXnIfpw Ah[nbpsS ssZÀLyhpw DÄs¸sSbpÅ
FÃmhnhc§fpw \ÂIpI
 Yes
 No
AsX
AÃ
15.
Have you experienced any associated anxiety or depression?
 Yes
\n§Ä¡v Ft¸msg¦nepw D¡WvTtbm, hnjmZ tcmKtam, D­mbn«pt­m?
AsX
If yes, please provide details including dates and durations:
D­v F¦nÂ, hn«p\n¶ XobXnIfpw Ah[nbpsS ssZÀLyhpw DÄs¸sSbpÅ FÃmhnhc§fpw \ÂIpI
 No
AÃ
16.
Please provide any additional information that you feel is important:
{]m[m\yapÅXmbn \n§Ä¡v tXm¶p¶ IqSpXembpÅ hnhc§Ä Fs´¦nepw Ds­¦n Ah Zbhmbn \ÂIpI
UWQuest_BackNeck_Ver1.0
Declaration {]Jym]\w
I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld any material
information that may influence the assessment or acceptance of this application.I agree that this form will constitute part
of my application for insurance(s) and that failure to disclose any material fact known to me may invalidate my
insurance(s).
Fsâ Gähpw \à AdnhnÂ, Rm³ \ÂInbncn¡p¶ D¯c§Ä kXyamWv F¶pw, Cu At]£bpsS kzoIcn¡ens\tbm,
Asæn AXnsâ aqey \nÀ®bs¯tbm _m[n¡p¶ bmtXmcphnhchpw Rm³ ad¨v h¨n«nÃm F¶pw, Rm³ ØncoIcn¡p¶p.
Cu t^mw, C³jzd³kn\mbpÅ / C³jzd³kpIÄ¡mbpÅ Fsâ At]£bpsS `mKw Bbncn¡pw F¶pw, CXn Fsâ
AdnhnepÅ Fs´¦nepw `uXnIhnhc§Ä \ÂIm³ hn«pt]mbn«ps­¦nÂ, Fsâ C³jzd³kns\ /C³jzd³kpIsf AXv
Akm[phm¡pw F¶pw Rm³ k½Xn¡p¶p.
Name & Signature of treating doctor
NnInÕn¡p¶ tUmIvSdpsS t]cpw, H¸pw

Name & Signature of the Life to be insured
sse^v C³jzÀ sNt¿­p¶ BfpsS t]cpw, H¸pw
/
/
Date
XobXn
A Joint Venture between Dabur Invest Corp. & Aviva International Holdings Limited
Aviva Life Insurance Company India Ltd
Head Office: Aviva Tower, Sector Road, Opp. DLF Golf Course, DLF Ph- V, Sector 43, Gurgaon-122003. Haryana India.
Registered Office: 2nd Floor, Prakashdeep Building, 7 Tolstoy Marg, New Delhi-110001. India
Um_À C³shÌv tImdpw, Ahnh CâÀ\mjW tlmÄUn§vkv enanänUpw X½nepÅ Iq«pkwcw`w
Ahnh sse^v C³jqd³kv I¼\n C´y en.
Bhnh ShÀ, skIvSÀ tdmUv, UnFÂF^v tKmÄ^v tImkn\v FXncmbn, UnFÂF^v s^bvkv 5, skIvSÀ 43, KpdmtKm¬þ122003. lcnbm\ C´y
dnPntÌUv Hm^nkv: cm­mw \ne, {]ImivZo]v _nÂUn§v, 7 tSmÄtÌmbn amÀ¤v, \yq UÂln þ 110001, C´y
Tel/ sSen:+91 (0) 124 270 9000 Fax/ ^mIvkv: +91 (0) 124 257 1210.
www.avivaindia.com Email/ CuþsabvÂ:customercare@avivaindia.com