Medical Needs Analysis

Name* This field is required.

First Name

Last Name

ID number* This field is required.

Email* This field is required.

example@example.com

Phone Number* This field is required.

Province * This field is required.

City* This field is required.

Your current occupation?* This field is required.

Employer's name?* This field is required.

Do you currently have medical aid?* This field is required.

Yes

Which medical aid are you currently on?

Medshield: Which plan are you currently on?

Bestmed: Which plan are you currently on?

Bonitas: Which plan are you currently on?

Discovery: Which plan are you currently on?

Fedhealth: Which plan are you currently on?

Momentum: Which plan are you currently on?

Profmed: Which plan are you currently on?

Keyhealth: Which plan are you currently on?

Medihelp: Which plan are you currently on?

Have you been on a medical aid before?* This field is required.

Yes

How many years in total have you been on medical aid ?* This field is required.

Who will be on the medical aid ?* This field is required.

Please choose a monthly premium for medical aid that you feel comfortable with.

R0 - R5000

R5001 - R1000

R10000 +

Spouse Date of birth

Date

Child's Date of birth

Date

Child's Date of birth

Date

Child's Date of birth

Date

Adult Date of birth

Date

Adult Date of birth

Date

Planning to grow your family ?* This field is required.

Yes

Do you want a medical savings account?* This field is required.

Yes

Current income before deductions?* This field is required.

Your income can influence your monthly premium.

In one year: How often do you/your family visit a GP?* This field is required.

0 times

1 - 5 times

6 - 10 times

11 + times

In one year: How often do you/your family visit a Dentist ?* This field is required.

0 times

1 - 2 times

3 - 4 times

5 + times

In one year: How often do you/your family visit an Optometrist?* This field is required.

0 times

1 - 2 times

3 - 4 times

5 + times

In one year: How often do you/your family visit a Pharmacy for prescribed medicine?* This field is required.

0 times

1 - 5 times

6 - 10 times

11 + times

In one year: How often do you/your family visit a Specialist?* This field is required.

0 times

1 - 2 times

3 - 4 times

5 + times

In one year: How often do you/your family visit a Physiotherapist?* This field is required.

0 times

1 - 5 times

6 - 10 times

11 + times

Do you or your family have any chronic diseases?* This field is required.

Yes

Do you or your family have any chronic diseases?

Addison's disease

Asthma

Bronchiectasis

Cardiac failure

Cardiomyopathy

Chronic obstructive pulmonary disorder

Chronic renal disease

Coronary artery disease

Crohn's disease

Diabetes insipidus

Diabetes mellitus types 1 & 2

Dysrhythmias

Epilepsy

Glaucoma

Haemophilia

Hyperlipidaemia

Hypertension

Hypothyroidism

Multiple sclerosis

Parkinson's disease

Rheumatoid arthritis

Schizophrenia

Systemic lupus erythematosus

Ulcerative colitis

Bipolar Mood Disorder

Family History?

Heart problems

Blood Pressure

Arthritis

Diabetes

Cancer

Osteoporosis

Blood clotting problems

Accept terms and conditions as per : www.multilinkfs.co.za* This field is required.