Health Insurance Quote – Relocations.io Portal

Basic Health Questionnaire – Health Insurance Quote – Portugal (Public)

This form helps us gather essential health information to provide you with an accurate and personalized insurance or health service quote. By completing the questionnaire, we can better understand your needs and offer tailored solutions that best suit your situation. All information provided will be kept confidential and used solely for the purpose of generating your quote. Please fill out the details below, and our team will get back to you with a customized quote as soon as possible.

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Toto pole je při zobrazení formuláře skryté

Status

E-mail*

Email to send quote and for potential service login

Your Name*

First Name Střední Last Name

Phone Number*

Country Code , Area Code and Number (eg. +351999123456 or +12025551234) | Please do not use dashes or brackets and please add “+” at the beginning

WhatsApp Number (If different from above)

We use WhatsApp as a communication tool | Format: Area Code and Number (eg. +351999999999 or +12029999999) | You may skip this if your main phone number is the same as your WhatsApp

Current Residence Location*

Adresa ulice Adresní řádek 2 Město Stát / provincie / region PSČ / poštovní směrovací číslo Country

Residence in Portugal

Please provide the address in Portugal which will be the insurance mailing address listed on the potential policy.

Adresa ulice Adresní řádek 2 Město Postal Code Country

NIF*

Tax Identification Number for Portugal

Health Questionnaire

Section related to identifying information

Date of Birth*

Profession | Work Status*

If retired, please list previous professions

Passport Number*

Passport Country of Issuance*

Země

Medical Information

Body Weight (Kg)*

Výška (cm)*

Are you taking any medications?*

Medication*

Since you answered “yes” to the previous question, please list all prescription and non-prescription medications you are currently taking. Please add only one per line. You may add additional lines by selecting “+” at the end of the box.

Medication Name

Dosage (mg)

How often

Do you have any medical conditions, diseases or related illnesses?*

Medical Conditions*

Since you answered “yes” to the previous question, please list all medical conditions that you may have. Please add only one per line. You may add additional lines by selecting “+” at the end of the box.

Condition

How long

Is it being treated?

Do you have any diagnosed allergies?*

Allergies*

Since you answered “yes” to the previous question, please list all diagnosed allergies that you. Please add only one per line. You may add additional lines by selecting “+” at the end of the box.

Allergy

Diagnosed Year

Do you take allergy medication?

Please check all that apply*

I am or used to be a smoker

I am or used to be a alcoholic

I am pregnant or have been pregnant previously

I have or previously had High Blood Pressure

I wear prescription Eye Glasses

I have asthma

I have Sleep apnea or insomnia

I have nothing that relates to me in this list

Have you had any surgeries in the past?*

Surgeries*

Since you answered “yes” to the previous question, please list all that you have had. Please add only one per line. You may add additional lines by selecting “+” at the end of the box.

Surgery Name

Reason for Surgery

Date of Surgery

Ongoing issue?