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. Do you smoke or have you in the last 12 months?
(This includes Nicotine replacements, Tobacco Products & Electronic Cigarettes)
(A pint of low strength beer or a standard size glass of wine is typically around 2 units)
In the last 5 years have you taken any recreational drugs such as Cannabis, Cocaine, Ecstasy, Heroin etc?
Have you ever had any of the following?
Angina, a heart attack, heart enlargement, heart failure, a heart valve defect or any other heart condition?
Stroke, mini stroke, transient ischaemic attack (TIA), brain haemorrhage, brain aneurysm or brain damage?
Peripheral vascular disease, or any disease or disorder of the aorta or arteries?
Diabetes, pre-diabetes, impaired glucose tolerance (IGT), raised blood sugar or sugar in the urine?
Any condition of the central nervous system (the brain, spinal cord and nerves), multiple sclerosis, optic neuritis, cerebral palsy, paralysis, Parkinson's disease, Alzheimer's disease or dementia?
Blurred or double vision, numbness, loss of feeling or muscle power, balance problems, tremor, or persistent pins and needles, dizziness, or facial pain serious enough to seek medical advice?
Cancer including less advanced, early or in situ cancer, Hodgkin's disease, lymphoma, leukaemia, melanoma, or a cyst or tumour of the brain or spine?
A positive test for HIV/AIDS?
Any psychiatric disorder or mental illness that has required hospital treatment or referral to a psychiatrist, or have you ever attempted suicide or self-harmed?
Ulcerative colitis, Crohn's disease or Barrett's oesophagus?
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?
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.
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)
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:
Please give details (Please include details of when the condition was diagnosed, any tests carried out, any medication and whether you are completely recovered)
Have any of your natural parents, brothers or sisters been diagnosed with, or died from, any of the following before age 60?
Please give details including, how many members of your family, what the conditions were and ages
Do you take part in any of the following?
Do you currently ride a motorbike?
Have you ever been banned from driving?
During the last three years, have you spent more than 90 days in total in Africa, the Caribbean, Russia, Thailand or Ukraine?
Are you currently living outside of, or during the next 12 months do you intend to spend more than 30 days outside of:
Within the last 30 days have you:
Do you want to add any of the below specific covers to your Protection policies?
I consent for the relevant insurer to contact my GP surgery to request medical information pertinent to my application
GP Surgery - Name and Location
Submit
