Medical Questionnaire

Insurers ask a range of questions to assess how they will treat your application. In order to help us place your insurance application with the correct insurer and to make sure the application goes as smoothly as possible, please answer the following questions to the best of your ability. Whilst some may seem somewhat invasive, each question will help with the process.

Your First Name

Your Last Name

Phone

Date of Birth

Postcode

What is your trouser or dress size?

Height

Weight

Do you smoke or have you in the last 12 months?

Yes

(This includes Nicotine replacements, Tobacco Products & Electronic Cigarettes)

If not, have you ever smoked in the past? If so, when did you stop?

How many alcoholic drinks do you have in a week?

(1 drink is classed as a pint of normal strength beer, a glass of wine or a 25ml serving of spirits)

In the last 5 years have you taken any recreational drugs such as Cannabis, Cocaine, Ecstasy, Heroin etc?

Yes

If you answered yes to any of the previous questions please give details of when the diagnosis was made, any investigations you have had, any medication you are taking and whether you have recovered fully or partly.

In the last 5 years have you had any of the following?

Mental illness including anxiety, stress or depression, insomnia, or eating disorders, regardless of whether or not you have seen a doctor?

Asthma, chronic obstructive pulmonary disease (COPD), or any other condition affecting your lungs or breathing (other than hay fever)?

Raised blood pressure or raised cholesterol other than fully resolved pregnancy related high blood pressure?

A lump, growth, polyp or tumour of any kind, or a mole or freckle that has bled, itched, become painful, changed colour or increased in size, regardless of whether or not you have consulted a doctor?

Chest pain, an ECG or any other heart investigations?

An abnormal cervical screen (smear test) or abnormal mammogram?

None of these

Apart from anything you may have already told us about, within the last TWO years have you:

Been prescribed any medication or treatment for a period of four weeks or more, or had any counselling?

Been referred to a specialist (even if you didn't attend, or haven't attended yet)?

Been under follow-up with your GP surgery, a specialist, hospital or clinic, including reviews or check ups you have been asked to attend even if you didn't?

Been absent from work or unable to perform your daily activities due to illness, disorder or injury for more than two weeks at a time?

Had, or been advised to have, any medical investigations (even if you didn’t attend, or haven’t attended yet)? This includes blood tests, biopsy, ultrasound, x-ray, CT, MRI, othe scans, or a scope (internal camera)

None of these

Please give details (Please include details of when the condition was diagnosed, any tests carried out, any medication and whether you are completely recovered)

Apart from anything you've already told us about:

Are you waiting for the results of any test or investigation?

In the last three months have you had any of these symptoms, even if you have not consulted a doctor? {Unexplained weight loss},{A lump, growth or cyst}, {Bleeding from the bowels or change in bowel habit}, {Blood in your urine},{A persistent cough lasting more than three weeks},{A mole or skin blemish which has changed}

Are you currently experiencing anything that you might go to your doctor about?

None of these

Please give details (Please include details of when the condition was diagnosed, any tests carried out, any medication and whether you are completely recovered)

Please give details including, how many members of your family, what the conditions were and ages

Are your parents still alive? If so, how old are they? If not, what age did they pass away?

Do you take part in any of the following?

Underwater diving

Mountaineering or rock climbing

Flying (other than as a fare paying passenger), hang gliding or paragliding

Motorcar or motorcycle sport

Parachuting, skydiving or BASE jumping

None of these

Do you ride a motorcycle, scooter or moped on the road?

During the last 5 years have you been disqualified from driving for a motoring offence or convicted of careless or reckless driving?

Do you currently ride a motorbike?

Yes

During the last three years, have you spent more than 90 days in total in Africa, the Caribbean, Russia, Thailand or Ukraine?

Yes

Are you currently living outside of, or during the next 12 months do you intend to spend more than 30 days outside of:

Yes

Within the last 30 days have you:

Experienced any of the following symptoms: a cough, breathing diyculties, a high temperature or fever, or a loss or change to your sense of taste or smell; or

Been diagnosed with Coronavirus (COVID-19); or

Self-isolated for any other reason, or had contact with someone who's been con{rmed or suspected to have Coronavirus (COVID-19)?

Do you want to add any of the below specific covers to your Protection policies?

Fracture Cover

Private Diagnostics

Private Medical Insurance

I consent for the relevant insurer to contact my GP surgery to request medical information pertinent to my application

Yes

GP Surgery - Name and Location

Thanks for submitting!