Financial Agent Solutions Ltd
Medical Questionnaire 01. Basic Details 02. Your Lifestyle - Part 1 2.1. Smoker Status
Please confirm your smoker status (cigarettes, cigars, pipe, loose tobacco, herbal cigarettes, any nicotine replacement therapy, and electronic cigarettes). We will carry out random tests to confirm non-smoker status: Occasioner smoker Regular smoker Ex-smoker (stopped less than 12 months ago) Ex-smoker (stopped more than 12 months ago) Ex-smoker (stopped more than 24 months ago) Ex-smoker (stopped more than 5 years ago) Never smoked
EX-SMOKER should not have smoked any cigarettes, cigars, a pipe (including shisha/hookah), used vapes, e-cigarettes, or nicotine replacements.
2.2. Alcohol Consumption
In an average week, how many alcoholic drinks do you have?
Here are some examples of drinks:
a pint of beer/cider 0 0 - 5 5 -12 more than 12
an average-sized glass of wine 0 0 - 5 5 -12 more than 12
a single measure of spirits (25 ml) 0 0 - 5 5 -12 more than 12
2.3. Have any of the following ever applied to you in relation to your alcohol consumption:
1. Have you ever been advised to reduce your alcohol intake because you were drinking too heavily? Yes No
2. I have attended or been advised to attend a hospital or a medical facility due to an injury, illness, or incapacity whilst under the influence of alcohol? Yes No
3. I have used or been referred to a specialist support service or counselor eg: Alcoholics Anonymous or Community Alcohol Team? Yes No
4. Have you been advised to have a scan, biopsy, blood test, or other investigation to check if your liver is functioning correctly? Yes No
5. Have you ever taken recreational drugs, such as cannabis, ecstasy, cocaine, methadone, heroin, anabolic steroids, or similar substances, in the last 10 years? Yes No
If you answered Yes, provide more Details about it:
2.4. In the last 10 years, have any of the following applied to you in relation to drug use?
I have used recreational drugs (examples of recreational drugs include cannabis, amphetamines, cocaine, ecstasy, hallucinogens, opiates such as heroin, methadone, or buprenorphine, solvents, or anabolic steroids). Yes No
I have attended or been advised to attend a hospital or medical facility due to an injury, illness, or incapacity while under the influence of drugs. Yes No
I have used or been referred to a specialist support service or counselor in relation to my drug intake, e.g., Narcotics Anonymous or Community Drugs Team. Yes No
I have misused, overused, or been addicted to any medication, whether prescribed by a doctor or not. Yes No
If you answered Yes, provide more Details about it:
2.5. In the last 5 years, have any of the following applied to you?
I have received a penalty for drink driving (a penalty can be a fine, a driving ban, or imprisonment). Yes No
I have received a penalty for drug driving (a penalty can be a fine, a driving ban, or imprisonment). Yes No
03. GP Details 3.1. General Practitioner (GP) Details:
3.2. Existing Cover
Do you already have any Life Cover, Critical Illness / Serious Illness or Income Protection Cover? Yes No
Within the last 12 months, have you applied for any other cover with any insurer, regardless of whether a policy has been issued or not? Yes No
If you answered Yes, provide more Details about it:
04. Occupation Details 4.1. What is your main occupation? Please enter an occupation with the closest match. This will help us process your application as quickly as possible.
4.2. Do you work in or with the armed forces or reserve forces? Yes No
4.3. Apart from commuting between your home and a fixed place of work, does your job involve driving more than 25,000 miles per annum? Yes No
4.4. Do you work less than 16 hours per week? Yes No
4.5. Is your job predominantly office based/ clerical or in one of the following industries: retail, catering, education or healthcare? Yes No
4.6. Have you been self-employed for 2 years or more? Yes No
4.6. Select any of the following that form part of your job:
50 % or more of your time is spend driving: Yes No
Working outside at height over 40ft for more than 5 hours during a typical week: Yes No
Carrying, lifting, working with machinery or tools: Yes No
Handling hazarduous substance, e.g explosives, asbestos: Yes No
Working offshore on oil rig, gas platform or at sea e.g. support vessels, fishing or merchant marine: Yes No
Working underwater or underground: Yes No
Flying other than as a fare-paying passenger: Yes No
Other duties not olready disclosed, including forestry, quarrying, road workers, driving construction vehicles or use of heavy plant machinery or vehicles: Yes No
NONE OF ABOVE: Yes No
If you answered Yes, provide more Details about it:
05. Covid-19 5.1. In the last month have you tested positive for the Coronavirus, been personally advised to self- isolate by a medical professional or the NHS111 but have not been diagnosed with Coronavirus, had a new continuous cough and / or high temperature, or had direct contact with someone who’s been confirmed or suspected to have Coronavirus? Yes No
5.2. Have you ever tested positive for Covid-19 (Coronavirus)? Yes No
5.3. Post viral syndrome, continuous fatigue, tiredness, long/chronic covid, ME (Myalgia encephalo-myelitis), or fibromyalgia? Yes No
If you answered Yes, provide more Details about it:
06. Lifestyle - Part 2
6.1. In the next 12 months, do you intend to spend more than 4 weeks overall (i.e. in total across all of these areas) in the Middle East, Africa, Central or South America, Asia (ignore Japan, Hong Kong and Singapore), Ukraine, Russia or New Guinea? Yes No
6.2. In the last 5 years have you spent more than 3 consecutive months in Africa, India, Thailand or the Caribbean? (Includes Antigua, Bahamas, Barbados, Bermuda, Cuba, Dominican Republic, Grenada, Haiti, Jamaica, Trinidad and Tobago)? Yes No
6.3. Do you take part in or intend to take up any hazardous activities? Yes No
6.4. Have you ever tested positive for HIV, Hepatitis B or C or are you awaiting the results of such a test? Yes No
If you answered Yes, provide more Details about it:
07. Family History 7.1. Before the age of 65, have any members of your immediate family (natural parents, brothers or sisters) had any of the following medical conditions: Breast, Ovarian, Colon or Bowel Cancer or any other cancer, Heart Attack, Angina, Cardiomyopathy, Stroke or Diabetes, Multiple Sclerosis, Muscular Dystrophy, Parkinson's, Dementia / Alzheimer's Disease, Huntington's, Motor Neurone Disease or Polycystic Kidney Disease? Yes No
7.2. Are there any other conditions that run in your family that you have had, or have been advised to have screening for? Yes No
If you answered Yes, provide more Details about it:
08. Your Health 8.1. Have you ever had or do you currently have any of the following:
Cancer, Leukaemia, Hodgkin's disease, Lymphoma, brain or spinal tumour? Yes No
Heart disease or disorder, including heart attack, angina, cardiomyopathy, heart murmur, heart surgery or procedure, palpitations, irregular heart beat or chest pain? Yes No
Stroke, transient ischaemic attack (TIA), brain haemorrhage or permanent brain injury through an accident? Yes No
Multiple sclerosis, optic neuritis, epilepsy, paralysis, muscular dystrophy, parkinson's disease, dementia or alzheimer's disease, cerebral palsy, motor neurone disease or any disorders of the brain or nerves? Yes No
Raised blood pressure or raised cholesterol, Deep Vein Thrombosis, disease or disorder of the blood vessels including the aorta and arteries of the leg or neck or any condition affecting the blood such as anaemia or thalassaemia? Yes No
Diabetes, sugar in the urine, raised blood sugar, low blood sugar, glucose intolerance or thyroid problems? Yes No
Schizophrenia, bipolar disorder / manic depression, psychosis, paranoia or have you ever required hospital treatment as an inpatient for any mental illness? Yes No
If you answered Yes, provide more Details about it:
8.2. Apart from any condition you have already told us about, have you had any of the following in the last 5 years:
Lump, cyst, growth or skin lesion of any kind that has bled, become painful, itchy, changed colour, increased in size or that you have been advised to monitor (including photographic surveillance)? Yes No
Mole or freckle that has bled, become painful, itchy, changed colour, increased size or that you have been advised to monitor (including photographic surveillance)? Yes No
Raised blood pressure or raised cholesterol, Deep Vein Thrombosis, disease or disorder of the blood vessels including the aorta and arteries of the leg or neck or any condition affecting the blood such as anaemia or thalassaemia? Yes No
Numbness, tremor, tingling, pins and needles, dizziness, facial pain or visual disturbance including blurred or double vision? Yes No
Seizures, fits, fainting, blackouts or memory loss? Yes No
Any disorder of the digestive system, liver, stomach, oesophagus, pancreas, colon or bowel, including Gastric ulcer, Hepatitis, Pancreatitis, Colitis or Crohn's disease? Ignore minor indigestion, heartburn, appendicitis (operated and fully recovered) or irritable bowel syndrome (IBS) that only cause occasional mild discomfort and for which you have not required investigation or hospital referral and none are planned. Yes No
Any disorder of the kidneys, bladder or prostate, including blood or protein in the urine or urinary tract infection? Yes No
Any mental disorder, including stress, anxiety, panic attacks, depression, nervous breakdowns or eating disorders? Yes No
Any respiratory or lung disorder, including asthma, bronchitis, COPD (COAD), emphysema, bronchiectasis or sleep apnoea? Yes No
Anaemia, antiphospholipid syndrome or blood disorder? Yes No
If you answered Yes, provide more Details about it:
8.3. Apart from any condition you have already told us about, have you had any of the following in the last 5 years:
Suffered from continuous fatigue, tiredness or fibromyalgia? Yes No
Had any pain or other problems relating to your back, neck, joints, bones or muscles including arthritis, ankylosing spondylitis, slipped disc, rheumatism or gout? Yes No
Had any disorder of the eyes including blindness or problems with your sight? (conjunctivitis, sight problems fully corrected by glasses, contact lenses or laser eye treatment for short/long sight or cosmetic reasons can be ignored) Yes No
Had any disorder of the ears including deafness or difficulty hearing? (Ear syringing can be ignored and please ignore simple earache and ear infections that have resolved leaving no continuing hearing loss). Yes No
Had any disease of the skin, including psoriasis or dermatitis? Yes No
Any gynaecological disorder, including abnormal cervical smears, or breast conditions which have required investigations, referral to a specialist or treatment? Infertility treatment, Miscarriage / termination, uncomplicated pregnancy / caesarean section, thrush, routine scan / blood test for pregnancy, routine cervical smear (normal result), HRT (no investigations involved) can be ignored. Yes No
Required more than 2 weeks off work for any medical condition, illness or injury not already mentioned? (Please ignore flu or colds from which you've fully recovered and pregnancy where no complications were present). Yes No
If you answered Yes, provide more Details about it:
09. Recent and Current Health 9.1. Are you currently pregnant? Yes No
9.2. In the last 6 months have you experienced any unintentional or unexplained weight loss? Yes No
9.3. Apart from any condition you have already told us about, have you had any of the following in the last 5 years: Required more than 2 weeks off work for any medical condition, illness or injury not already mentioned? (Please ignore flu or colds from which you've fully recovered and pregnancy where no complications were present). Yes No
9.4. Apart from anything you’ve already told us about, in the last 3 years have you been advised to have or undergone any medical investigation such as blood tests, x-rays, urine tests, scans, exploratory surgery, biopsies / tissue sampling or internal camera investigation? Yes No
9.5. Apart from anything you have already told us about in this form, do you have any impairment or medical complaints that you intend seeking medical advice for, or are you currently awaiting the results of any investigations? Yes No
If you answered Yes, provide more Details about it:
10. Access to Medical Reports Act Declaration – YOUR ELECTRONIC DECLARATION OF CONSENT
