Medical Questionnaire

Medical Questionnaire
Important information:-

How we use your data- We need to make it clear how we will use your personal information, including information about your health.

We will use your data to provide a quote and also for pricing and underwriting analytics. We may share your information with selected third parties for assessing and servicing your application.

The Insurer may request medical information as part of the application or up to six months after the plan has started to confirm the information you have given. Before we can do this we will ask for permission under the Access to Medical Reports Act

Please answer all questions accurately and honestly and to the best of your knowledge. Failure to give correct answers could void a future claim. If you’re not sure about including any information, then you should include it.
Name*

First NameLast Name
Your Existing Life Assurance
Do you have any existing plans life, critical illness, or income policies in place? *
Please give us details on your answer above*
About you
What is your height?*
Metres *
Feet and*
Inches*
What is your weight? *
Kilos*
Lbs and *
Ozs*
What is your current trouser or dress size?*

Smoker Status - Which of the following applies to you?*
How many cigarettes did/do you smoke per day *
How many units of alcohol do you drink in a typical week in units?*
Explainer - (1 beer = 2 units) - (175ml wine = 2 units) - (1 spirit measure = 1 unit)
Have you ever been medically advised to reduce your alcohol consumption*
Please give us details on your answer above*
Please provide details about your driving. Do any of these apply.
I’ve been disqualified from, or charged with driving whilst unfit due to alcohol or drugs*
I ride a motorbike, scooter or moped on the road*

Your Physical Health
Have you ever had, or do you currently have, any of the following?
- Any form of cancer, tumour, lymphoma, leukaemia or any growth or cyst of either the brain or spine?
- Heart disease or disorder, circulatory disease or diabetes?
- A stroke, brain haemorrhage or surgery to your blood vessels in the brain or neck?
- Multiple sclerosis or been diagnosed with any neurological disorder?
Serious Illnesses*
Please give us details on your answer above*
Your Physical Health in the last Five Years only

Apart from anything you’ve already told us about, during the last 5 years have you had, or do you currently have, any of the following:

Any form of

• Numbness

• Pins and needles

• Tremor

• Change in skin sensation

• Tingling

• Muscle weakness

• Loss or reduced power in limbs, including amputation

• Difficulty with coordination

• Persistent tiredness or fatigue
Physical health*
Please give us details on your answer above*

Your Physical Health in the last Five Years only.

Any form of joint pain, arthritis, neck, back, spine, or muscle pain or stiffness?

Including:

• Back or neck pain, stiffness or surgery

• Joint pain, stiffness or surgery (including that affecting your knees, shoulders, hips, ankles, wrists or hands)

• All forms of arthritis

• Repetitive strain injury (RSI)

• Gout

• Muscle strain
Pain*
Please give us details on your answer above*
Any condition affecting your ears or hearing, or your eyes or vision that is not wholly corrected by spectacles or lenses?*
Please give us details on your answer above*

A tumour, lump, cyst, polyp, growth, or any mole/naevus thathas bled, changed in appearance or become painful?*
Please give us details on your answer above*
Asthma, bronchitis, or any other disorder affecting your lungs or breathing?*
Please give us details on your answer above*
Any stomach, digestive system, bowel, liver or blood disorder?*
Please give us details on your answer above*
Any disorder of the kidney, bladder, prostate or thyroid?*
Please give us details on your answer above*

Your Medical History in the last 3 years only

Apart from anything you’ve already told us about, during the last 3 years have you:-
Been prescribed medication or treatment regularly for a period of four consecutive weeks or more, or have you been under review from your doctor or a medical professional? *
Please tell us more about the answer
Been referred to a specialist or have or been advised to have any investigations?*
Please tell us more about the answer*
Do you have any symptoms for which you haven’t yet sought medical advice, or are you awaiting referral, investigation, results or treatment for anything else?*
Is there any other important information you would like to provide?*
Through illness or injury in the last two years, do any of the following apply?
- Currently off work
- Altered duties in the last two years
- Reduced hours in the last two years
- Required more than four consecutive weeks off work
Illness or injury*
Please give us details on your answer above*

Have you had treatment at a hospital for Coronavirus?*
Please give us details on your answer above*
Mental Health
During the last 5 years have you had, or do you currently have any of the following?
- Depression
- Anxiety
- Stress
- Any other mental health condition
Mental health*
Please give us details on your answer above*

Finally - Your Family
Have any of your parents, brothers or sisters ever been diagnosed with or died from any of the following conditions before the age of 60?
- Heart attack or angina
- Stroke
- Diabetes
- Cancer
- Leukaemia or lymphoma
- Multiple sclerosis
- Huntington’s disease
- Cardiomyopathy
- Polycystic kidney disease
- Muscular dystrophy
- Motor neurone disease
- Alzheimer’s disease
- Parkinson’s disease
- Haemochromatosis
- Familial colon polyps
- Any other disorder which runs in your family for which you’ve received or been advised to have screening for
Your family*
Please give us details on your answer above*
Your GP

The insurer may request a medical report if they need more information to underwrite your plan.
Your Medical Practice Name*
Your Medical Practice Postcode*
Are there any other important points or information that we should know?
Thank you for your help in completing this form, which will help us to recommend the right solution for you.

Please click the button on the bottom right to send the information securely to us.
Should be Empty:

About you