The Protection PlatformData Capture Form

The Protection PlatformData Capture Form
Personal details
Full name*
Date of birth*

MonthDayYear
Gender*
Address*
Email*
Telephone*
General
Q How tall are you?
This can be in feet and inches or centimetres
Q How much do you weigh?
This can be either stones or pounds. Female only – if you’re pregnant, please tell us how much you weigh before you were pregnant
Q What is your job?
This needs to be your main job (e.g. the one you spend most time doing)
Q How much did you earn in the last year?
This is your taxable income. Include overtime, commission and bonuses but do not include income from investments or any income that would continue if you can’t work. If you’re selfemployed, please tell us your taxable income (e.g. earnings after costs and before tax)
Q Do you have another job?
Q Are you currently off work, workingreduced hours or altered your dutiesto sickness or injury?
Smoking
Q What is your average daily consumption?
Cigarettes
Cigars
Tobacco
Q Which of the following best describes you?

I’ve never smokedI used to smoke but stopped over a year agoI’ve smoked in the last year but not every dayI’ve vaped or used e-cigarettes in the last yearI’ve used other nicotine replacement productsin the last year
Family health
Q Have your birth parents, brothers, or sistershad any of these before they were 65?

Heart attack, angina or strokeCardiomyopathyDiabetesBowel cancer or bowel polypsBreast or ovarian cancer (females only)Any other cancerMuscular dystrophy, Huntington’s diseaseor motor neurone diseaseMultiple sclerosis, Parkinson’s disease or Alzheimer’s diseasePolycysticI don’t knowNo
Q In the last 5 years have you had any of these?

Asthma, sleep apnoea or anything else affectingyour lungs or breathingCrohn’s, colitis, IBS, or anything else affecting yourstomach, bowel or digestive systemKidney stones, urinary infection or anything elseaffecting your kidneys, prostate, bladder or urineAnything affecting your liver or pancreasNo
Q In the last 5 years have you hadany of these?

Back pain, sciatica, whiplash or anythingelse affecting your back or neckArthritis, gout or anything else affecting yourbones, joints, ligaments, tendons or musclesNumbness, pins and needles, muscleweakness, tremor or difficulty with coordinationNo
Q In the last 5 years have you hadany of these?

Tinnitus, labyrinthitis, or anything elseaffecting your ears, hearing or balanceImpaired, blurred or double vision, opticneuritis or anything else affecting your eyesChronic fatigue syndrome, ME, fibromyalgiaor persistent tirednessNo
Mental health
Q In the last 5 years have you had any of these?

DepressionAnxietyStressAny other mental health issueNone of these
Q Have you ever had any of these?

Eating disorderBipolar disorderManic depressionSchizophreniaPsychosisNone of these
Q Have you ever:

Tried to take your own life?Had thought about taking your own?Intentionally harmed yourself?Had thoughts about harming yourself life?None of these?
Physical health
Q Have you ever had any of these?

Cancer, cancer-in-situ, leukemia, Hodgkin’sdisease or any other tumour?Heart attack, irregular heartbeat,cardiomyopathy, valve disorder or any otherheart condition or heart surgery?A stroke, TIA, brain hemorrhage or damage orsurgery to your brain?Multiple sclerosis, epilepsy, Parkinson’s or anyother disorder of the brain or nervous system?A positive test, or are you waiting on the resultsof a test for, HIV, AIDS or hepatitis B or C?No
General health
Q Have any of these applied to you in thelast 3 years?

I’ve taken or been prescribed treatment for4 weeks or moreI’ve been asked to attend a follow-up or regularreviews with a GP, hospital or clinicI’ve been advised to see a specialist or to haveany tests, scans, investigations or counsellingNo
Q Have you had any of these in the last 3months, even if you haven’t seen a doctor?

Lump, growth or hardening affecting either testicleBleeding from the bowel or a change in bowel habitA cough lasting more than 3 weeksA fit or seizureA mole or skin blemish which has changed inappearanceNo
Q Do any of these apply to you?

I’ve been treated at hospital for CoronavirusI’ve experienced symptoms of Coronavirus thathave lasted longer than 12 weeks (long COVID)Neither of these
Lifestyle
Q How many of these do you drink per week?
Pints of beer, lager or cider
Glasses of wine
Measures of spirits
Other alcoholic drinks
Q Have any of these applied to you?

I’ve been advised by a medical professional tocut down or stop drinking alcoholI’ve been referred for alcohol or drug specialistsupport such as Alcoholics or NarcoticsAnonymousI’ve used recreational drugs in the last 10 yearsNo
Q Are you involved in any of these?

Armed forces (including reserves)Scuba divingPrivate flying, gliding or parachutingMotor car or motorcycle sportMountaineering or rock climbingSailing at sea or powerboat racingMartial arts or combat sportsOff-piste snow sportsCompetitive horse ridingProfessional or semi-professional sportNo
Q Have any of these applied to you?

I’ve been banned from driving or convicted ofdangerous or careless driving in the last 5 yearsI ride a motorbike, scooter or moped on the roadNo
Q Have you lived, worked or travelled outsidethe UK or European Union in the last 5 years,or do you have any plans to do so in thenext year?

YesNo
Q How many years have you lived in the UK?
By ‘lived in the UK’ we mean you must have lived in the UK for more than 9 months each year, paid UK taxes, had your main home here and have financial ties (e.g. bank accounts or mortgage)
Q Do you have existing Life insuranceor are you applying for any other Lifeinsurance?

YesNo
Q Do you have existing Income Protectioninsurance or are you applying for anyother Income Protection insurance?

YesNo
Q Do you have existing Critical Illnessinsurance or are you applying for anyother Critical Illness insurance?

YesNo
Additional information
Q Please confirm your GP Surgery name?
Should be Empty:

The Protection PlatformData Capture Form

Personal details

General

Smoking

Family health

Mental health

Physical health

General health

Lifestyle

Additional information