Diabetes Protection Assessment

1
Source
2
The type of diabetes I have is...* This field is required.
Type 1
Type 2
Other
3
When were you diagnosed with Diabetes?
Please Select
Please Select
Within the last 3 months
3-6 months ago
6-12 months ago
1-7 years ago
7-15 years ago
15 years +
4
Have you had diabetes more than 3 months?* This field is required.
YESNO
5
When were you diagnosed with Diabetes?* This field is required.
With the last 3 months
3-6 months ago
6-12 months ago
1-7 years ago
7-15 years ago
15 years +
6
When were you diagnosed with diabetes?To the best of your knowledge
Date
Day
Month
Year
7
When was your most recent Diabetes review?
Please Select
Please Select
Within the last 12 months
Within the last 18 months
18 months +
8
Was your last diabetes review within the last 12 months?* This field is required.
YESNO
9
When was your most recent diabetes review?* This field is required.
Within the last 12 months
12-18 months ago
18 months +
10
When was your most recent diabetic review?to the best of your knowledge
Date
Day
Month
Year
11
Has your diabetes ever caused any complications?* This field is required.example: problems with your eyes, pain or tingling in your hands or feet, protein in your urine, fatty liver, coma, amputations, ketoacidosis ect
YESNO
12
Has your diabetes ever caused any of the following?* This field is required.Please select all that apply...
Tingling, numbness, pain or loss of sensation in your fingers, toes or feet
Eye problems or retinopathy which haven't needed treatment
Eye problems or retinopathy which have needed treatment
Foot ulcers
Protein or albumin in your urine
Fatty Liver
None of these
13
Regarding your Fatty Liver* This field is required.
I no longer have a fatty liver, and I'm no longer under review
I still have a fatty liver, and I'm under review
I still have a fatty liver, but I'm no longer under review
14
Regarding your tingling/pain?* This field is required.Please select the appropriate option
I've been diagnosed with Neuropathy
I previously had tingling/pain, but this has now been resolved (No Neuropathy)
My tingling/pain is linked to something else (No Neuropathy)
I'm unsure as it's currently being investigated
15
Have you ever had nephrotic syndrome, nephropathy (kidney damage caused by diabetes), glomerulonephritis, protein in the urine due to diabetes cystic disease of the kidneys or any other chronic disease or disorder of the kidneys* This field is required.Where there is only small amounts of protein present, known as microalbuminuria, this does not need to be disclosed under this question.
YESNO
16
Since you were diagnosed, have you ever stayed in hospital or visited A&E because of your diabetes?
YESNO
17
Since you were diagnosed, have you ever stayed in hospital or visited A&E because of your diabetes?* This field is required.
YESNO
18
Since you were diagnosed, have you ever stayed in hospital or visited A&E because of your diabetes?* This field is required.
No
Yes, 1-2 years ago
Yes, 2-5 years ago
Yes, 5-10 years ago
Yes, 10 years+
19
When did you last stay in hospital or visit A&E because of your Diabetes?
Please Select
Please Select
Within the last 12 months
1-2 years ago
2-5 years ago
5 years +
20
When did you last stay in hospital or visit A&E because of your diabetes?To the best of your knowledge
Date
Day
Month
Year
21
Do you know the result of your most recent HbA1c test?
Yes, as a percentage
Yes, as a reading in mmol/mol (millimoles per mole)
I don't know my last reading
22
What was your most recent HbA1c reading?
23
What was your most recent HbA1c reading?
24
Do you know your HbA1c reading from your last diabetes review?* This field is required.This is a blood test that provides an average of your blood sugar levels over the past 2-3 months and is normally shown as a number such as 57mmol
YESNO
25
At your most recent review, what were you told about your diabetes control?* This field is required.Very Good: 49mmol or below / 6.6% or below Good: 50 - 57mmol / 6.7% - 7.4% Ok: 58 - 69mmol / 7.5% - 8.5% Could be improved: 70 - 80mmol / 8.6% - 9.5% Unsatisfactory: 81mmol or higher / 9.6% or higher
It's very good
It's good
It's Ok
It could be improved
It's not good enough
26
In the last 5 years, how many hypoglycaemic or hyperglycaemic attacks have you had that needed medical attention?
27
Do you take insulin for your diabetes?* This field is required.
YESNO
28
Have you had any of the following?* This field is required.Please select all that apply...
Chronic kidney or Liver disease
Angina, Heart Attack, Stroke or TIA
Any form of cancer
Suicide attempt within the last 5 years
None of these
29
Was your last Heart Attack, Stroke or TIA more than 12 months ago?* This field is required.
YESNO
30
Was your last Cancer more than 5 years ago?* This field is required.
YESNO
31
What is your height and weight?* This field is required.Imperial or Metric
Height
Weight
32
Which of the following describes you?* This field is required.This includes vaping or nicotine replacement products
I've never smoked
I used to smoke but stopped over a year ago
I smoke
33
When did you last smoke?
Please Select
Please Select
1-2 year ago
2-3 years ago
3-5 years ago
5 years +
34
When did you last smoke?To the best of your knowledge
Date
Day
Month
Year
35
Have you ever required medication, time off work or have you seen a medical professional for any of the following?Please select all that apply...
Depression, Anxiety or Stress
Eating disorder, Bipolar or Schizophrenia
Tried to take your own life
Had thoughts of taking your own life
None of these
36
Was your last suicide attempt more than 10 years ago?
YESNO
37
Was your last suicidal thought more than 5 years ago?
YESNO
38
What date was you diagnosed with depression, anxiety or stress?To the best of your knowledge
Date
Day
Month
Year
39
Are you on medication for your mental health? Including anxiety, stress or depression
YESNO
40
How many days have you been signed off work in the last 5 years?Due to your mental health, anxiety or depression to the best of your knowledge
41
What date was your last signed off work?Due to your mental health, anxiety or depression to the best of your knowledge
Date
Day
Month
Year
42
In the last 5 years have you had any of these?Please select all that apply...
Raised blood pressure
Raised cholesterol
A growth, lump or cyst
Anaemia, blood clot or anything else affecting your blood
Liver, pancreas, kidney or bladder issues such as stones
Bowel or digestive system issues such as IBS or Crohn's
Lungs or breathing issues such as Asthma or COPD
None of these
43
What date was your blood pressure first noticed to be raised? To the best of your knowledge
Date
Day
Month
Year
44
Are you on medication for your blood pressure?
YESNO
45
What is your latest blood pressure reading?To the best of your knowledge
46
What date was your cholesterol first noticed to be raised?To the best of your knowledge
Date
Day
Month
Year
47
Are you on medication for your cholesterol?
YESNO
48
What is your latest cholesterol reading?To the best of your knowledge
49
Have any of these applied to you in the last 5 years? You don't need to include things you've already told us about i.e. your diabetesThink about but not limited to asthma, blood pressure, cholesterol or depression ect
I've taken or been prescribed treatment for 4 weeks or more
I've been asked to attend a follow-up or regular reviews with a GP, hospital or clinic
I've been advised to see a specialist or to have any tests, scans, investigations or counselling
I have another medical condition(s) to disclose
No
50
Do you have any other medical information we need to know about? You don't need to include your diabetes* This field is required.Think about but not limited to asthma, blood pressure, cholesterol or depression ect.
I have another medical condition(s) to disclose
No
51
MetLife Lead
52
Based on your diabetes details, we'd like to speak with you to complete our assessment, and provide your quote. We do guarantee 100% of people we speak with will be quoted. Speaking with you helps us secure the right cover and allows us to share your options . Would you like to proceed?* This field is required.
YESNO
53
IMPORTANT - Due to the volume of interest in our services we request those looking to receive a quote verify their interest in a diabetes-friendly life insurance solution. Which best explains your situation?* This field is required.
I’ve changed my mind. Don’t contact me, I’m not interested.
Yes! Please assess my application and contact me, I’m interested!
54
Have your birth parents, brothers, or sisters had any of these before they were 65?Please select all that apply...
Bowel, Ovarian or Breast Cancer
Polycystic Kidney Disease
Heart Attack, Angina or Stroke
MS, Parkinson's, or Alzheimer's Disease
Muscular Dystrophy, Huntington's or Motor Neurone Disease
I don't know
None of these
55
Please submit contact details below as they would appear on any insurance documentation* This field is required.
First Name
Last Name
Date of birth
Email Address
Phone Number
56
What is your permanent address for insurance documents?* This field is required.First line and post code is all we require at this stage
Street Address
Street Address Line 2
City
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
57
Name of your GP Surgery?An insurance company may need to speak with your GP first before insuring you, so having this information up front helps speed up the process of getting you covered. We need the name of the surgery and the local area it's in.
Name of the GP surgery
Local area the GP surgery is in
Should be Empty: