Med. questionnaire

PLEASE COMPLETE IN BLACK INK AS THIS DOCUMENT MAY BE CONVERTED TO AN ELECTRONIC IMAGE
Full Name of Proposer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Date of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Proposal Number or Reference (if known). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Date Application Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of Insurance Company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MEDICAL CONDITIONS
QUESTIONNAIRE
The purpose of this standard questionnaire is to enable the insurer to reach a decision on your proposal in the shortest
possible time. In many cases the insurer will be able to do so without the usual further enquiries although it still
reserves the right to obtain further information if thought necessary. (You need only complete the section or sections
which are applicable to your situation.)
It will help if you answer the questions in as much detail as possible although it is realised that in some cases you may notknow precise medical terms. Please say on the form if you are unsure about the information requested.
The questionnaire incorporates 11 sections covering medical conditions which often appear on proposals. These are listedoverleaf. When you have completed the relevant section or sections please read the following and then sign and date thedeclaration:- It is important that you tell the insurer about anything which might affect the insurer’s judgment and acceptance of theaccompanying proposal.
Please disclose such information even if you have doubts about its relevance.
Appointed representatives, brokers and intermediaries submitting proposal forms and this accompanying questionnaireto the insurer, do so on your behalf and all information will be treated in the strictest confidence but, if you would prefer,you can return this direct to the Chief Medical Officer at the insurer’s head office.
Appointed representatives, brokers and intermediaries submitting proposal forms and this questionnaire to the insurerdo not have authority to conclude contracts on behalf of the insurer.
A copy of the policy conditions and/or your completed proposal form and medical conditions questionnaire are availablefrom the insurer on request.
DECLARATION
This questionnaire is part of the proposal and if you do not include all relevant facts it could result in you being
quoted the wrong terms, a claim being rejected or reduced, or your policy being invalid.
I have read all the notes relevant to this medical conditions questionnaire and declare that as far as I know and believe: the answers and information I have given are true and complete I have disclosed all the facts that could affect the acceptance of the accompanying proposal I acknowledge that even if this questionnaire is submitted through a broker or agent I have ensured that all details arecorrect and complete I agree that this medical questionnaire is part of the proposal on my life made to the above company I agree to notify the insurer of any changes in my circumstances or health between completing this medical conditionsquestionnaire and commencement of the policy.
CONTENTS
The appropriate section of the questionnaire should, if possible, be completed at the same time as the proposal.
If there is not sufficient space for any reply please continue on the blank page at the end.
SECTION 1. EPILEPSY
Has it been described as any particular type? (Please give details) b) If YES, please give details including results What tablets have you taken in the past? (if different types please list them) eg Epilim, Epanutin a) Are you being followed up or on any treatment now? Are you permitted to hold a driving licence? SECTION 2. ANXIETY/DEPRESSION
a) On what date did you first consult a doctor? b) Have you been given a precise diagnosis? (If so, please give details) d) When have you been off work with this complaint? a) What tablets have you taken in the past? eg Librium, Valium, Lithium, Prothiaden b) What tablets are you taking now? (Please give name and dosage) c) When and where is your next medical appointment? a) Have you ever had treatment as a hospital out-patient or seen a psychiatrist? b) If YES, please say when and where and what treatment you received a) Have you ever been an in-patient at a hospital? a) Was your anxiety/depression triggered by any particular factor? a) Have you ever tried to take your own life? b) If YES, please say when and give details SECTION 3. ARTHRITIS
Which form of arthritis do you suffer from? eg Rheumatoid, Osteoarthritis a) What is the extent of your disability? Do you use a walking stick or other mobility aids? a) Have you had, or are you waiting for, an operation? b) If YES, please give details including dates a) What drugs have you taken in the past? (eg Brufen, Indocid, Myocrisin, Naprosyn) with dates if possible b) Have you ever taken steroids? eg Betnesol, Ledercort, Prednesol c) What drugs are you taking now? (Please give name and dosage) How often are you being followed up, and by whom? How much time have you taken off work with this condition? Please give dates and duration SECTION 4. ASTHMA/BRONCHITIS
When was this diagnosis first made? (If so, please give details) In what circumstances is an attack brought on? (eg exercise, stress or allergy?) a) What is the name of the drugs you have received in the past? eg Becotide, Bricanyl, Franol, Intal, Ventolin b) What treatment are you taking now? (tablets and/or inhalers) Please give name, dosage and frequency of use a) Have you ever taken steroids? eg Prednisolone, Pulmicort a) Have you ever been admitted to hospital as an emergency? a) Have you ever had any hospital investigations? Have you been off work with this complaint? (Please say when and for how long) a) Do your symptoms wake you up at night? If you use a peak flow meter and record the results please quote your lowest and highest readings in the last SECTION 5. HIGH BLOOD PRESSURE
How was it discovered or why was your blood pressure measured at that particular time? a) Did you have any investigations? (eg X-ray, ECG, blood lipids) b) If YES, please give full details including results What tablets have you taken in the past? (if different types please list them) eg Aldactide, Moduretic, Navidrex, Aldomet, Betaloc, Inderal, Tenoretic, Tenormin, Trasicor b) If YES, please give name of tablet, dosage and how often you take the tablets c) What are the arrangements for following you up? a) When was your last blood pressure reading? a) Have tests on your urine always been normal? SECTION 6. GROWTHS, CYSTS, LUMPS AND TUMOURS
b) Is it still there or has it been removed? If the growth has been removed, please tell us: d) How? (eg local anaesthetic, full operation, cryosurgery) a) What treatment have you had following its removal? (eg tablets, radiotherapy etc) What, in medical terms, was it called? (If known) For how long were you followed up, and how often? a) Are you being followed up or on any treatment now? SECTION 7. STOMACH/BOWEL COMPLAINTS
Have you been given a precise diagnosis? (please give details) What tablets have you taken? eg Aludrox, Gaviscon. Tagamet, Zantac a) Have you had a barium meal or any other investigation? b) If YES, please give details including the date and result a) If you have had an operation, please say when a) Are you being followed up or receiving any treatment now? c) If you have been discharged from follow up, when was this? Have you been off work with this complaint? (Please say when and for how long) SECTION 8. GYNAECOLOGICAL COMPLAINTS
ABNORMAL SMEARS
HYSTERECTOMY
a) Was there any other treatment connected with this? If you have been discharged, when was this? OTHER GYNAECOLOGICAL PROBLEMS
Please give details here and by answering such of the questions above as are appropriate SECTION 9. GENITO URINARY DISORDERS
a) Please state the precise diagnosis (eg Cystitis, Kidney Stones, Prostatitis, Pyelonephritis) a) Have you had any investigations? (eg IVP, Cystoscopy) b) If YES, please give details including dates and results Please give details of treatment (tablets, operations etc) If your symptoms have occurred more than once please give dates and durations: If such checks have been completed, please state last date Have you been off work with this complaint? (Please say when and for how long) SECTION 10. BACK TROUBLE
Do you know the precise diagnosis? (Please give details) a) Has it kept you off work or affected your lifestyle? b) If YES please give relevant dates and durations or details Please give details of treatment (eg names of tablets, physiotherapy etc) SECTION 11. DIABETES
Is your diabetes treated with (please tick box) Has your treatment been changed in the last 2 years? a) How frequently do you attend your Hospital, Clinic or GP for monitoring? (Please tick the box) More than once per year Yearly Less frequently If Clinic or Hospital, please give address b) How frequently do you monitor your diabetes, and is this by testing your blood or urine for glucose (sugar)? c) Please indicate your usual test results (if applicable) Please tick more than one box if this would give a more accurate reflection of the range of your results d) What was the date and result of your last HbA1c (glycosylated haemoglobin)? Have you ever had a diabetic (hyperglycaemic) or insulin (hypoglycaemic) coma? (If so please give date(s) and details) Have you ever had problems with any of the following? Tick as appropriate and give further details on the blank page where applicable Feet or Legs (for example numbness or tingling) Heart or circulation Kidneys (for example albumin or protein in urine) Have you been off work with this complaint? (please say when and for how long)

Source: http://www.pensiontransfersolutions.com/documents/form_Medical_History_Questionnaire.pdf