Membership Registeration

Vitality Health Insurance - Membership Application Form

Medical History (Please select the appropriate medical condition applicable to you)

Allergies
Anemia
Angina
Any Medication for Any Condition
Asthma
Back Neck Problem
Benign Cancer
Bladder Infection
Chronic Bronchitis
Congenital Heart Abnormalities
Congenital Kidney Disorder
Cystic Fibrosis
Depression or Psychiatric Disorder
Diabetes Mellitus
Disorder of the Digestive System
Embolism
Emphysema
Endocrine Disorder
Epilepsy
Fibroid
Gall Bladder Disease
Gout
HIV Positive
Heart Attack
Heart Disease
Hepatitis
Hepatitis B
High Blood Pressure

High Cholestrol Level
Intestinal Fibrosis
Jaundice
Kidney Stone
Leukemia
Life Insurance Rejected
Liver Condition
Lung Disease
Malaise
Malignant Cancer
Migraine
Nephritis
Pregnancy
Rheumatic Arthritis
Rheumatic Fever
Severe Recurrent Diarrhoea
Smoking
Spectacle or Contact Lenses
Stroke
Fibroid
Thrombosis
Thyroid Disorder
Tuberculosis
Ulcer
Varicose Veins
Hepatitis
No Specific Risk