Medical Questionnaire

Please complete this form fully and honestly. The information you provide will be kept confidentially. Read through the form before you start completing it. Be aware that failure to disclose a medical condition can invalidate your application and/or any subsequent claim.
Full Name*

First NameLast Name
Title*

MrMrsMissMsOther
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
What is your Marital Status?*

MarriedSingleCivil partnerDivorcedWidowedSeparated
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Future Address (if moving within 3 months)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your occupation?*
What is your employment status?*

Full time employeePart time employeeContract WorkerSelf-employedRetiredUnemployedHouse Person
What industry do you work in?*
What is your salary?*
How many weeks does your employer pay you if off work due to sickness or injury?
How many business miles do you drive on average each year?*
Please ignore travel to and from your usual place of work
What percentage of your time do you spend doing manual work?*
By manual work we mean carrying or lifting, moving goods, working with tools or machinery, crawling or kneeling
Do you have a second job?*

YesNo
If yes, provide details including occupation, hours worked per week, etc.
Do you work in any of the following?*

The Armed Forces or as a member of the Armed Forces ReservesOffshore in the oil, gas or fishing industryWorking at heights over 10 feet (3m)Working undergroundWorking underwaterWorking with explosives or firearmsAviation (except as a fare paying passenger)None of the above
During the last 2 years have you spent more than 30 consecutive days outside the UK?*

YesNo
During the last 2 years have you spent more than 90 consecutive days in Africa, the Caribbean, Russia, Thailand or Ukraine?*

YesNo
During the next 2 years do you intend to spend more than 30 consecutive days outside the UK?*

YesNo
If yes, please provide details of countries, duration and reasons why
Not including your occupation, do you regularly taken part in any of the following activities, or do you intend to do so within the next 6 months? If yes, tick all that apply. If no, tick "None of the above"*

Caving or potholingFlying (other than as a fare-paying passenger)Hang gliding or paragladingMotor car sport driving or motorcycle sport ridingMounteneering or rock climbingParachuting, sky diving or BASE jumpiingPowerboat racingSailing other than inlandUnderwater divingAny Extreme sport, for example bungee jumping, canyoning, white water raftingNone of the above
Do you already have or have you previously applied for life or critical illness cover?*

YesNo
If yes, please provide details (including company name, cover type, amount)
Have you ever been turned down or been offered special terms by any company?*

YesNo
If yes, please provide details (including company name, type of cover, amount and reasons for refusal/special terms)
Have you ever made a waiver, income protection or critical illness claim*

YesNo
If yes, please provide details
Have you used any tobacco or nicotine products, including patches or vapers, in the last year? *
If not, have you ever smoked/ when did you stop?
If yes, how many cigarettes/cigars/pipes/vapes/patches do you use per day?
Please specify the number and name of product that you use
What is your weight?*
Please specify if kg or lb
What is your height?*
Please specify if m or in
What is your dress size?
Specify if measure is in meters or inches
What is your trousers size?
Specify if measure is in meters or cm
How many units of alcohol do you drink per week?*
One unit = a single measure of spirits, 1 glass of wine (125 ml), or half-pint of beer
Have you ever been advised by a health professional to reduce your drinking or smoking on medical grounds?*

YesNo
Have you ever?*

Been given medication to help reduce the amount of alcohol you drink or been referred to or been seen by an acohol specialistAttend or been advised to attend an acohol support groupBeen told that you have any liver damage which may have been caused by alcoholNone of the above
During the last 5 years have you injected non-prescription drugs or have you ever taken drugs other than on medical advice? *
What is the name of your GP?

First NameLast Name
What is the address of your GP?*
What is the phone number of your GP?

Area CodePhone Number
In the last 6 months have you lost or gained more than 7lbs in weight through non diet loss? If so, how much and over what period and reason? *
Have you ever had or do you currently have any of the following?*

Cancer, Leukemia, Hodgkin's disease, Lymphoma, Melanoma, Brain or Spinal Tumour or CystHeart condition (including heart attack, angina, heart surgery or any other disorder of the heart)Stroke, Mini Stroke, Transient Ischaemic attach (TIA), Brain Hemorrhage, surgery to your blood vessels or permanent brain injury through accidentAny Neurological Condition or Visual Disturbance, including Multiple Sclerosis, Muscular Dystrophy, Motor Neurone disease, Optic or Retrobulbar Neuritis, Parkinson's Disease, Paralysis, Epilepsy, Alzheimer's Disease, Dementia or Cerebral PalsyAny other disorder of the arteries (including disease in the legs or of the aorta)Diabetes or sugar in the urineMental illness that has required treatment or referral to psychiatrist including anorexia or bulimiaAny disorder of the Central Nervous System (brain, spinal cords, nerves) not already mentionedTested positive for HIV, or are you waiting for the result of an HIV test?None of the above
For every condition you have selected in the above question, please complete:

Name of the condition blanks
Date first occurred   Date
Date that it was diagnosed   Date
What are the symptoms Please add appropriate blank
How often symptoms occur?
List any medications you take
Date that the last time the symptoms occurred   Date
How many days off have you had relating to the above condition
When was your most recent time off work relation to the above condition   Date
Are you awaiting further investigations/tests/consultations regarding this condition
(Please provide any additional information in the last section of this form)
During the last 5 years have you seen a doctor, nurse or other health professional for:*

Raised blood pressure, raised cholesterol or condition affecting blood or blood vessels, for example anaemia, excess sugar in the blood, blood clot, deep vein thrombosis?Any condition affecting your kidneys, bladder or prostate, for example blood or protein in the urine, kidney or bladder stones?Any condition affecting your stomach or bowel, for example Crohn's disease, ulcerative colitis? Please ignore diarrhoea, food poisoning, sickness or vomiting, stomach upset, provided no hospital investigation was advised or completedAny condition affecting your gall bladder, liver or pancreas, for example hepatitis or fatty liverAny condition affecting your lungs or breathing, for example asthma, emphysema, sleep apnoea, sarcoidosis? Please ignore hay feverLupus, fibromyalgia, gout or any type of arthritis, neck, back, spine or joint trouble, for example rheumatoid arthritis, sciatica?Anxiety, depression or any mental illness that has required treatment or counselling, or chronic fatigue syndromeAny condition affecting your tyroidAny condition affecting your ears or hearing, for example Meniere's disease or deafness. Please ignore simple earache or ear infections that have resolved leaving no continuing hearing lossAny condition affecting your eyes or vision, not wholly corrected by spectacles, lenses or laser treatment, for example catarat or blindnessA growth, lump, polyp or tumour of any kindA mole or freckle. Please ignore birthmarks where no treatment or specialist referral has been advisedChest pain, palpitations or irregualr heartbeatParalysis, numbness, persistent tingling or pins and needles, tremor, facial pain other than dental pain or memory loss, dizziness or balance problemsAny other illness, injury or disability that's kept you off work for a continuous period of 2 weeks or more, for example stress, headaches, trapped nerve. Please ignore colds and flu from which you have fully recovered and pregnancy where no complications were presentNone of the above
For every condition you have selected in the above question, please complete:

Name of the condition blanks
Date first occurred   Date
Date that it was diagnosed   Date
What are the symptoms Please add appropriate blank
How often symptoms occur?
List any medications you take
Date that the last time the symptoms occurred   Date
How many days off have you had relating to the above condition
When was your most recent time off work relation to the above condition   Date
Are you awaiting further investigations/tests/consultations regarding this condition
(Please provide any additional information in the last section of this form)
Apart from anything you have already told us about in this application, during the last 12 months have you:*

Had any medical condition, illness or injury that you have received treatmetn over a continuos period of 4 weeks or more? Please ignore minor accident and injuries provided they have not kept you off work for 2 weeks or moreBeen referred to or had any investigations in hospital, for example biopsy, scan, ECG?None of the above
If you did not select 'None of the above', please provide additional information in the last section of this form
Apart from anything you have already told us about in this application, do you have any medical condition or symptom that:

Your doctor or nurse told you to see them about during the next 3 weeks? Please ignore consultations for repeat prescriptionsDuring the last 3 months have you had any of the following: unexplained bleeding, weight loss, lump or growth; unexplained changes with walking, movement or mobility, numbness or tingling, mental functioning, or changes to your vision; mole or freckle that's bled or changed in appearance; a cough that's lasted for 3 weeks or more; any other symptom that you may see a health professional about for the first timeNone of the above
If you did not select 'None of the above', please provide additional information in the last section of this form
Are you currently waiting for any medical consultation, check-up, investigation, scans or tests? If yes, provide details
Your Family's Medical History - Have any of your natural parents, brothers or sisters, before the age of 60, had any of the following? (Please answer any relation to the family members above that you know about. If you do not know about any of these relatives, answer 'Don't Know')

Heatr attack, Angina, Stroke or DiabetesCancerCardiomyopathy (primary disorder of the heart muscle)Multiple SclerosisMyotonic DystrophyBowel Disease or disorder including Polyposis of the colon (Familial adenomatous)Polycystic Kidney DiseaseKennedy's DiseaseMotor Neurone DiseaseMuscular DistrophyHuntingdon's DiseaseParkinson's DiseaseAlzheimer's DiseaseAny other condition that runs in your family and that you are receiving regular follow up or screening forNone of the aboveDon't Know
If you did not select 'None of the above' or 'Don't Know', please provide additional information:
Name of the condition
Family member diagnosed with the condition
Age when diagnosed
Is this family member still alive?
PLEASE PROVIDE ANY ADDITIONAL INFORMATION RELATING TO ANY CONDITIONS THAT YOU HAVE TOLD US ABOVE, OR ANYTHING ELSE THAT MAY BE RELEVANT TO THIS APPLICATION
DIRECT DEBIT DETAILS FOR MONTHLY PREMIUMS
Name of Bank *
Account Number*
Sort Code*
Preferred payment date
Trust Details

First Trustee:
Name of Trustee
Date of Birth of Trustee   Date
Trustee's Address   Street Address   Address Line 2   City   State   Zip
Telephone number      Phone Number
Email address   Email

Second Trustee (optional):
Name of Trustee
Date of Birth of Trustee   Date
Trustee's Address   Street Address   Address Line 2   City   State   Zip
Telephone number        Phone Number
Email address  Email
Should be Empty:

For every condition you have selected in the above question, please complete:

For every condition you have selected in the above question, please complete:

If you did not select 'None of the above', please provide additional information in the last section of this form

If you did not select 'None of the above', please provide additional information in the last section of this form

DIRECT DEBIT DETAILS FOR MONTHLY PREMIUMS

Trust Details