Medical questionnaire.
Please remember to ensure that all responses to the questions below are in accordance with your best knowledge, as failure to disclose information regarding your health may result in the invalidation of the insurance policy and the denial of any compensation payout.
Your details
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Name, Middle name
Surname
Date of Birth
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Month
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Day
Year
Email Address
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1. Do you partake in physical labour, and if so, what percentage of your occupation involves manual work?
No
Yes - Write down what percentage of the work that is manual labour
1.b. - Manual work percentage
2. Height
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3. Weight
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4. Please provide your dress size (for women) or waist size (for men).
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5. Have you experienced a sudden, unexpected change in weight recently?
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Yes
No
5.b. Please provide details on why the sudden change in weight occurred.
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6. Do you smoke cigarettes, including electronic cigarettes and other nicotine substitutes, or have you smoked in the past 12 months?
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Yes
No
6.b. How many cigarrettes per day?
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7. Have you ever smoked in the past?
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Yes
No
7.b. How long did the smoking habit last, and when did it occur? Please write the period of smoking from (date) to (date).
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8. Do you drink alcohol?
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No alcohol
Yes
8.b. How many units of alcohol do you consume weekly? 0.5 liters of beer equals 3 units; a glass of wine equals 1.5 units; 25ml of vodka/whisky equals 1 unit.
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9. Have you received treatment for alcohol-related illness or sought advice to limit alcohol consumption?
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No
Yes
9.b. Please provide more details about alcohol-related illness or advice to limit alcohol consumption.
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10. Have you ever taken drugs or medication that weren't prescribed by a doctor?
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No
Yes
10.b. Please describe the details (when this was, what drugs or medication, how long it lasted, is it still ongoing?).
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11. Have you resided outside of the United Kingdom or spent more than 30 days abroad in the last 5 years?
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No
Yes
11.b. Please describe the details (when this was, which countries, how long it lasted, is it still ongoing?).
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12. How many times a week do you regularly exercise for at least 30 minutes?
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I don't exercise
Once a week
Twice a week
Three times a week
Four times a week
Five times a week
Six times a week
Every day
13. Do you work in any of the following sectors?
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Armed forces
Private plane flights
Professional diver
Work on a trawler, on a ship, sea work
Underground tunnelling
Mining, underground work
On a drilling platform
Working at heights above 15 metres
Merchant seaman
Prison service
Police
Professional athlete
None of the above
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14. Do you partake in any of the following activities?
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Diving
Private plane flights
Mountain climbing
Motor sports
Parachute jumps
Sky diving
Base jumping
Caving
Motorboat racing
Sea sailing
Full contact martial arts
Boxing
Horse riding
Winter sports beyond holiday skiing or snowboarding for pleasure
Motorcycle, scooter, moped riding
None of the above
15. Have you ever lost your driving licence or the right to operate vehicles?
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No
Yes
15.b. Please provide details, when did you lose your driving licence and for what reason and for how long?
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16. Have you ever been convicted by a court?
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No
Yes
16.b. Please provide details, when and for what reason were you convicted by the court?
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17. Are you a professional driver or does your job require driving a car, van, or lorry?
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No
Yes
17.b. How many miles do you cover annually while at work?
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Medical History
18. Have you ever suffered from any of the following mentioned illnesses or been referred for tests related to them?
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Cancer, leukemia, malignant lymphoma, Hodgkin's disease, brain or spinal tumor, including brain or spinal growth
Heart diseases, including myocardial infarction, angina, cardiomyopathies (heart muscle diseases), or heart valve disease, chest pain, heart attack, enlarged heart, heart defect, or other heart disease?
Heart diseases, including myocardial infarction, angina, cardiomyopathies (heart muscle diseases), or heart valve disease, chest pain, heart attack, enlarged heart, heart defect, or other heart disease?
Arterial diseases (such as artery narrowing, arteriosclerosis, arterial inflammation, or plaque buildup in arteries) including diseases of the legs or aorta?
Multiple sclerosis, optic neuritis, Parkinson's disease, paralysis, cerebral palsy, epilepsy?
Motor neuron disease, dementia, or any other central nervous system disorder? Muscular dystrophy?
Diabetes or sugar in the urine?
Any psychiatric disorders or mental illness (including anxiety, stress, or depression) that required hospital treatment or referral to a psychiatrist, or have you ever attempted suicide or had suicidal thoughts?
Blurred or double vision, paresthesia, loss of sensation or muscle strength, balance problems, or persistent stabbing or facial pain serious enough to seek medical advice?
None of the above
Medical History
18.b. Please provide more details about each selected illness or condition.
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Exact disease/illness name: When did the first symptoms appear: (month/year) When did the symptoms of the disease last occur: (month/year) Are the symptoms recurring or is the disease completely cured? Severity of symptoms: How many days of work have you missed in the past 2 years due to the above-mentioned illness? Are you under continuous medical supervision? (If yes, please provide details) When was the last time you saw a doctor regarding the aforementioned illness? (month/year) What type of treatment has been prescribed to you? Are there any future procedures, surgeries, or additional tests planned for the aforementioned illness? (If yes, please provide details) APPLIES to elevated blood pressure, cholesterol, sugar levels. What were the results of the last tests related to the above-mentioned disease, and when were the tests conducted (month/year)? If you don't know the test results or whether they were good, bad, or within normal range? Other information about the illness.
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19. Do you have, or have you had within the last five years, any of the following conditions? Please mark affirmatively even if you have not yet consulted a doctor about this condition.
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Asthma or pneumonia?
Anxiety states, stress, or depression?
Tumours, growths, cysts; bleeding from moles or freckles, causing pain, changing colour, or increasing in size?
Any thyroid diseases?
High blood pressure?
Chest pain, heart rhythm disturbances, heart murmurs, or elevated cholesterol?
Attacks of illness, epilepsy, seizures, fainting, loss of consciousness, numbness, loss of sensation or tingling of limbs or face, loss of balance or coordination, loss of muscle control?
Blindness, double or blurred vision, or other problems with the eye or both eyes? (Vision defects corrected through glasses or lenses do not need to be disclosed)?
Lung diseases, including sarcoidosis, other than asthma?
Stomach, intestinal, or other gastrointestinal diseases, including ulcers, ulcerative colitis, Crohn's disease, or irritable bowel syndrome?
Kidney diseases, bladder, urinary system infections, or other diseases of the urinary-sexual system, including blood and protein in the urine, or other sexually transmitted diseases?
Liver or pancreatic diseases, including cirrhosis of the liver or pancreatitis?
Gout, anaemia, or other blood diseases?
Hearing loss or other ear diseases, including ringing in the ears, labyrinthitis, or Meniere's disease?
Rheumatoid arthritis or degenerative joint disease, whiplash-related spinal injury, sciatica, discopathy, back pain, neck, shoulder, knee, or other neck or joint diseases?
Eating disorders, chronic and constant fatigue?
None of the above
19.b. Please provide more details about each marked disease.
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Exact name of the disease: When the first symptoms appeared: (month/year) When the last symptoms of the disease appeared: (month/year) Do the symptoms recur, or is the disease completely cured? Intensity of symptoms: How many days off work have you had due to the above disease in the last 2 years? Are you under constant medical supervision? (if yes, please provide details) When did you last see a doctor in relation to the above disease? (month/year) What type of treatment has been prescribed for you? Are any future procedures, surgeries, additional examinations planned in relation to the above disease? (if yes, please provide details) APPLIES TO high blood pressure, cholesterol, sugar. What was the last test result related to the above disease, and when were the tests conducted (month/year)? If you don't know the reading of the results, were the results good, bad, normal? Other information about the disease:
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20. Are you taking any medications prescribed by a doctor for conditions other than those previously mentioned, or in relation to any other treatment?
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No
Yes
20.b. Please provide the names of the conditions and the medicines for which you are taking medication or undergoing treatment.
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21. Have you ever had illicit drugs injected into your body, or have you ever taken drugs that were not prescribed to you? Please include recreational drugs (e.g., cocaine, heroin, marijuana, ecstasy)?
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No
Yes
21.b. Please provide the names of the drugs and the dates they were taken.
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22. Have you ever been diagnosed as a carrier of HIV, Hepatitis B or C, or are you currently awaiting results for such a test? (Please note: If the test result is negative, undergoing an HIV test in itself will not influence the terms of your insurance.)
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No
Yes
22.b. Please select the appropriate option.
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HIV/AIDS virus
Hepatitis B
Hepatitis C
Awaiting test result
23. Apart from the illnesses mentioned in the previous part of the application, have you, in the past two years, taken any medication where the treatment lasted more than four weeks?
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No
Yes
23.b. Could you please provide more details on this matter?
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24. Have you been referred to, treated at, or examined in a hospital or clinic?
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No
Yes
24.b. Could you please provide more details on this matter?
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25. Have you been absent from work or unable to carry out daily activities due to illness, ailment, or injury for more than two consecutive weeks?
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No
Yes
25.b. Please provide more details on this matter, including the reason, when it occurred, how long it lasted, and so forth.
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26. Apart from other instances, scans, tests, or examinations already confirmed earlier in the application, are you currently awaiting the results of any tests or examinations?
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No
Yes
26.b. Please provide more details on this matter. What test results are you waiting for?
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27. Do you have any signs or symptoms for which you intend to seek medical advice or treatment in the future?
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No
Yes
27.b. Please provide more details on this matter
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28. Do you suffer from a physical or mental ailment that limits or causes difficulties in performing daily activities or your profession?
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No
Yes
28.b. Please provide more details on this matter.
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29. If you're applying for income protection insurance, other than for appointments related to pregnancy prevention or pregnancy, or other cases mentioned in the application, have you seen a doctor in the last 12 months?
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No
Yes
29.b. Please provide more details on this matter.:
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Family history
30. Have either your parents or siblings been diagnosed with one of the following diseases before reaching the age of 60?
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Bowel Cancer
Breast Cancer
Ovarian Cancer
Another type of cancer
Myocardial Infarction
Heart Attack
Angina
Heart Disease
Polycystic Kidney Disease
Cardiomyopathy
Diabetes
Stroke
Alzheimer's Disease
Huntington's Disease
Motor Neurone Disease
Myotonic Dystrophy (muscular dystrophy)
Multiple Sclerosis
Parkinson's Disease
Other hereditary diseases
None of the above
30.b. Please list the names of diseases in parents or siblings prior to their 60th year of life and provide information such as: type of disease, age at diagnosis, and age at death, if applicable.
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Other insurance products
31. Have you ever had an insurance application (for life, illness, or income protection) rejected, accepted on special terms, or with exclusions applied?
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No
Yes
31.b. If 'YES', please provide details:
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DOCTOR AND SURGERY DETAILS
32. Please provide the details of your General Practitioner (GP), including their full name and the name and address of the clinic.
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33. Have you been registered at this clinic for longer than six months?
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Yes
No
33.b. Previous clinic: Could you please provide the details of your previous GP, including their name, address, and the name of the clinic?
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ADDITIONAL INFORMATION
34. Are there any other illnesses or information you wish to inform us about?
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No
Yes
34.b. Please provide more details on this matter.
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35. Please provide the details of the account from which the insurance premium will be deducted (sort code and account number), along with the payment day of each month (which should be from the 1st to the 28th).
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SIGNATURE
I, the undersigned, declare that all answers to the above questions are true and based on my best knowledge. I understand that providing false information may result in the denial of insurance coverage and claim pay out.
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Date
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Month
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Day
Year
SUBMIT
Should be Empty: