Kerry Donnelly Confidential Medical Questionnaire

Please note that failure to disclose information may result in non-payment of a claim

– Step 1 of 10

Name *

First

Last

Date of birth *

House or apartment number *

Street name *

Area *

Postcode *

Marital status *

Married
Single
Divorced
Separated
Cohabiting
Civil partnership

Mobile or Landline number *

Email *

Do you already have or have you previously applied for life or critical illness cover exceeding £250,000? *

If yes, is this policy to be cancelled when your new policy goes on risk? *

Have you ever made a waiver, income protection claim or critical illness claim? *

Have you ever been turned down or been offered special terms by any company? *

PLEASE COMPLETE YOUR DOCTOR DETAILS IN THE SECTION BELOW

Doctor / Surgery name *

Doctor / Surgery address *

Doctor / Surgery postcode *

Doctor / Surgery phone number *

PLEASE COMPLETE YOUR HEIGHT AND WEIGHT INFORMATION IN THE SECTION BELOW

PLEASE NOTE THAT FAILURE TO DISCLOSE INFORMATION MAY RESULT IN NON PAYMENT OF A CLAIM

Height in feet and inches or meters *

Weight in stone and pounds or kilos *

Have you recently lost or gained weight? If so how much, over what period and reason? *

Waist measurement in inches *

PLEASE COMPLETE YOUR SMOKING, DRINKING AND SUBSTANCE INFORMATION IN THE SECTION BELOW

PLEASE NOTE THAT FAILURE TO DISCLOSE INFORMATION MAY RESULT IN NON PAYMENT OF A CLAIM

Smoking Habits *

Currently smoking
Never smoked
Stopped smoking within the last 12 months
Stopped smoking between 12 months and 3 years
Stopped smoking between 3 years and 5 years
stopped smoking more than 5 year

Number of cigarettes per day?

Number of cigars per day?

If you are a previous smoker, please confirm how many you smoked on an average day *

Do you use patches, gum, e-cigarettes or liquid Cigs? If you do, please specify

How many units of alcohol do you drink per week? *

(One unit = a single measure of spirits, 1 glass of wine, or a half-pint of beer)

Have you ever been advised to reduce your drinking habits on medical grounds? *

Have you ever taken non-prescription drugs? (e.g. heroin, ecstasy, cocaine or steroids) If yes, please specify *

HAVE YOU EVER BEEN DIAGNOSED WITH ANY OF THE FOLLOWING?

I UNDERSTAND THAT FAILURE TO DISCLOSE INFORMATION IN THIS PERSONAL MEDICAL SECTION MAY RESULT IN NON PAYMENT OF A CLAIM

HIV infection *

(HIV can be caught through unsafe sex, intravenous drug abuse, blood transfusions undertaken outside of the European Union or surgery taken outside the European Union)

Cancer, Leukaemia, Hodgkin’s disease, Lymphoma, brain or spinal tumour *

Heart disease (including heart attack, angina, heart defects from birth or heart surgery) *

Stroke, brain haemorrhage or brain injury *

Multiple sclerosis, optic or retrobulbar neuritis, parkinson’s disease, paralysis, epilepsy, alzheimer’s disease, dementia or cerebral palsy *

Any other disorder of the arteries (including disease in the legs or of the aorta) *

Diabetes type 1 or type 2, or sugar in the urine *

Mental illness that has required treatment or referral to a psychiatrist *

WITHIN THE LAST 5 YEARS, HAVE YOU BEEN DIAGNOSED WITH ANY OF THE FOLLOWING?

I UNDERSTAND THAT FAILURE TO DISCLOSE INFORMATION IN THIS PERSONAL MEDICAL SECTION MAY RESULT IN NON PAYMENT OF A CLAIM

A mole or freckle that has bled, caused pain or changed in appearance or any lump or growth *

Chest pain, irregular heartbeat, raised blood pressure or raised cholesterol *

Asthma, bronchitis or any other respiratory disorder *

Numbness, loss of feeling or tingling of the limbs or face, loss of balance or co-ordination *

Seizures, fits, fainting or blackouts *

Within the last 5 years have you had any of the following? *

Any disorder of the eyes or ears, including blurred or double vision, or impaired hearing. (You can ignore sight problems corrected by glasses or contact lenses

Within the last 5 years have you had any of the following? *

Arthritis, back pain, sciatica, neck, knee or wrist pain or any other joint, bone or muscle disorder (including RSI)

Any disorder of the digestive system, liver, stomach, pancreas or bowel (including ulcers, hepatitis, colitis or Crohn’s disease) *

Any blood disorder *

Any thyroid disorder *

Any disorder of the kidney, bladder or genitor urinary system (including urinary tract infections and blood or protein in the urine) *

Treatment or a positive test for any disease which was transmitted sexually *

Depression, anxiety, stress, fatigue or nervous breakdown *

HEALTH CONSULTATION SECTION

I UNDERSTAND THAT FAILURE TO DISCLOSE INFORMATION IN THIS HEALTH CONSULTATION SECTION MAY RESULT IN NON PAYMENT OF A CLAIM

Other than consultations to do with the points you have already mentioned, have you had any medical consultations in the last 12 months (e.g. doctor, consultant, psychiatrist, hospital, clinic, osteopath) *

You do not need to give details of occasional consultations with your GP for just colds or flu, or for consultations for oral contraceptive pills, smear tests, well woman/man check ups where the results are normal.

Have you ever had (or been advised to have) any medical investigation, scan, test or attended hospital in the last 5 years? *

Are you awaiting any medical consultation, check up, investigation, scans or tests *

Have you been prescribed any medication or been given any other treatment in the last 12 months. *

Have you ever tested positive for HIV, Hepatitis B or C or are you awaiting the results of such a test *

Have you ever undergone any surgical procedure outside the European Union or been a recipient of blood products outside the European Union *

IF YOU HAVE ANSWERED YES TO ANY OF THE PERSONAL HEALTH QUESTIONS IN THE SECTIONS ABOVE, PLEASE PROVIDE MORE DETAILED INFORMATION IN THE NEXT SECTION

I UNDERSTAND THAT FAILURE TO DISCLOSE INFORMATION IN THIS PERSONAL HEALTH SECTION MAY RESULT IN NON PAYMENT OF A CLAIM

Name of condition 1

Date the condition first occurred

Date the condition last occurred

Please describe the symptoms

How often do the symptoms occur?

Do you take any medication for the condition? if so, please give details

How many days have you had off relating to the above condition?

When was your most recent time off work relating to above condition?

Are you receiving treatment for this condition?

Will you have to have any operation/treatment in the future related to this condition? If so can you specify the dates this is to occur?

Name of condition 2

Date the condition first occurred

Date the condition last occurred

Please describe the symptoms

How often do the symptoms occur?

Do you take any medication for the condition? if so, please give details

How many days have you had off relating to the above condition?

When was your most recent time off work relating to above condition?

Are you receiving treatment for this condition?

Will you have to have any operation/treatment in the future related to this condition? If so can you specify the dates this is to occur?

IF YOU HAVE ANY FURTHER MEDICAL DISCLOSURES, YOU CAN INCLDE THEM IN THE NOTES SECTION AT THE END OF THIS APPLICATION

FAMILY HISTORY SECTION

I UNDERSTAND THAT FAILURE TO DISCLOSE INFORMATION IN THIS FAMILY HEALTH SECTION MAY RESULT IN NON PAYMENT OF A CLAIM

FAMILY HISTORY

Have either of your natural parents, brothers or sisters suffered or died before the age of 65 from any of the following?

Heart disease *

Stroke *

Raised Cholesterol *

Cancer – breast *

Cancer – ovarian *

Cancer – Colo-rectal (e.g. cancer of the colon or Rectum) *

Cancer – Other (i.e. not breast, ovarian, or colo-rectal) *

Diabetes *

Multiple sclerosis *

Huntingtons Disease *

Polycystic Kidney disease *

Polyposis of the colon *

Any other hereditary disorder *

IF YOU HAVE ANSWERED YES TO ANY OF THE FAMILY HISTORY QUESTIONS IN THE SECTION ABOVE, PLEASE PROVIDE MORE DETAILED INFORMATION IN THE NEXT SECTION

I UNDERSTAND THAT FAILURE TO DISCLOSE INFORMATION IN THIS FAMILY HEALTH SECTION MAY RESULT IN NON PAYMENT OF A CLAIM

Family disease 1

Family member

Age the family member was first diagnosed

Family disease 2

Family member

Age the family member was first diagnosed

Family disease 3

Family member

Age the family member was first diagnosed

Family disease 4

Family member

Age the family member was first diagnosed

Is your father still alive? *

Is your mother still alive? *

What age is your father, or at time of passing? *

Up to 60
60 – 80
Over 80

What age is your mother, or at time of passing? *

Up to 60
60 – 80
Over 80

PASTIMES

Do you take part in any hazardous sports or pastimes, or do you intend to start? The following are examples, but you should include any activities that are hazardous
If your involvement is, or will be, limited to one occasion, for example a race day, a flying lesson, a trip in a hot air balloon or a team building exercise, and you have no intention of pursuing the activity further you need not disclose it.

Diving *

Flying *

Motor sports *

Mountaineering/rock climbing *

Do you ride a Motor-Cycle? *

Have you lived or worked outside of the UK for more than 3 months in the last 5 years, or do you intend to do so? *

If you have answered yes to any of the questions above, please provide some further information here

PLEASE PROVIDE DETAILS ABOUT YOUR OCCUPATION IN THE SECTION BELOW

PLEASE NOTE THAT FAILURE TO DISCLOSE INFORMATION IN THIS OCCUPATION SECTION MAY RESULT IN NON PAYMENT OF A CLAIM

What is your occupation? *

What is your salary? *

Do you ever work at heights over 10 feet? *

Do you ever work underground? *

Do you ever work underwater? *

Do you ever work offshore? (e.g oil or gas industry? *

Do you ever work with explosives or firearms? *

Do you ever work with the armed forces? *

Are you involved in any professional sports? *

Do you work in aviation (except as a fare paying passenger) *

If you have answered yes to any of the questions above, please provide some further information here

What percentage of time would you say you spend doing manual work? *

By manual work we mean carrying or lifting, moving goods, working with tools or machinery, crawling or kneeling

What manual work do you carry out?

What percentage of time would you say you spend driving? *

Business miles travelled per year? *

Hours worked per week? *

Are you currently absent from work? *

Have you had any time off in the last 2 years due to illness or injury? (Ignore minor ailments such as colds or flu if together they total less than 10 days per year) *

IF THERE IS ANY FURTHER INFORMATION YOU WOULD LIKE TO INCLUDE IN THIS APPLICATION SUCH AS FURTHER MEDICAL DISCLSOURES, PLEASE FEEL FREE TO INCLUDE THE INFORMATION HERE AND I WILL CONFIRM THE DETAILS WITH YOU *

PLEASE PROVIDE YOUR BANK DETAILS IN THE SECTION BELOW

Name of account holder *

Name of bank *

Account number *

Sort code *

Preferred payment date between 1st and 28th of the month *

I hereby confirm that the information included has been completed by myself and I have honestly disclosed any conditions that I have been asked about. I understand that any non-disclosures that later come about due to a claim being made may result in the insurer not paying out as I may not have been covered from the outset had I have previously mentioned any information which I decided to not make them aware of. By selecting the "YES" button below , I confirm that I am responsible for the accuracy of the information I have provided. *