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Financial Agent Solutions Ltd
Office 4a, City view Offices, 99 Long St,
Middleton Manchester, M24 6UN
www.financialagent.co.uk

Medical Questionnaire

01. Basic Details

Height (cm):
Weight (kg):
Trousers / Skirt Size (inch):

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:

EX-SMOKER should not have smoked any cigarettes, cigars, a pipe (including shisha/hookah), used vapes, e-cigarettes, or nicotine replacements.

How many cigarettes (including roll-ups) do you, or did you, smoke per day?

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, an average-sized glass of wine, a single measure of spirits.

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?

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?

3. I have used or been referred to a specialist support service or counselor eg: Alcoholics Anonymous or Community Alcohol Team?

4. Have you been advised to have a scan, biopsy, blood test, or other investigation to check if your liver is functioning correctly?

5. Have you ever taken recreational drugs, such as cannabis, ecstasy, cocaine, methadone, heroin, anabolic steroids, or similar substances, in the last 10 years?

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).
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.
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.
I have misused, overused, or been addicted to any medication, whether prescribed by a doctor or not.

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).
I have received a penalty for drug driving (a penalty can be a fine, a driving ban, or imprisonment).

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?
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?

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?
(Even if you have already selected an armed forces occupation title you must answer ‘Yes’ to this question if applicable).

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?

4.4. Do you work less than 16 hours per week?
If you are unemployed, a student, a houseperson, retired or a pensioner then answer "No" to this question.

4.5. Is your job predominantly office based/ clerical or in one of the following industries: retail, catering, education or healthcare?

4.6. Have you been self-employed for 2 years or more?

4.6. Select any of the following that form part of your job:

50 % or more of your time is spend driving:
Working outside at height over 40ft for more than 5 hours during a typical week:
Carrying, lifting, working with machinery or tools:
Handling hazarduous substance, e.g explosives, asbestos:
Working offshore on oil rig, gas platform or at sea e.g. support vessels, fishing or merchant marine:
Working underwater or underground:
Flying other than as a fare-paying passenger:
Other duties not olready disclosed, including forestry, quarrying, road workers, driving construction vehicles or use of heavy plant machinery or vehicles:
NONE OF ABOVE:

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?

5.2. Have you ever tested positive for Covid-19 (Coronavirus)?

5.3. Post viral syndrome, continuous fatigue, tiredness, long/chronic covid, ME (Myalgia encephalo-myelitis), or fibromyalgia?

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?

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)?

6.3. Do you take part in or intend to take up any hazardous activities?
Examples include, but are not limited to aviation (except as a fare-paying passenger or where it is your full-time occupation), parachuting, skydiving, hang-gliding, water sports, diving, mountaineering, caving, bouldering, motor sports, extreme sports (such as bungee jumping, base jumping, canyoning) etc. One day experience or taster sessions can be ignored.

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

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?

7.2. Are there any other conditions that run in your family that you have had, or have been advised to have screening for?

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?
Heart disease or disorder, including heart attack, angina, cardiomyopathy, heart murmur, heart surgery or procedure, palpitations, irregular heart beat or chest pain?
Stroke, transient ischaemic attack (TIA), brain haemorrhage or permanent brain injury through an accident?
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?
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?
Diabetes, sugar in the urine, raised blood sugar, low blood sugar, glucose intolerance or thyroid problems?
Schizophrenia, bipolar disorder / manic depression, psychosis, paranoia or have you ever required hospital treatment as an inpatient for any mental illness?

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)?
Mole or freckle that has bled, become painful, itchy, changed colour, increased size or that you have been advised to monitor (including photographic surveillance)?
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?
Numbness, tremor, tingling, pins and needles, dizziness, facial pain or visual disturbance including blurred or double vision?
Seizures, fits, fainting, blackouts or memory loss?
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.
Any disorder of the kidneys, bladder or prostate, including blood or protein in the urine or urinary tract infection?
Any mental disorder, including stress, anxiety, panic attacks, depression, nervous breakdowns or eating disorders?
Any respiratory or lung disorder, including asthma, bronchitis, COPD (COAD), emphysema, bronchiectasis or sleep apnoea?
Anaemia, antiphospholipid syndrome or blood disorder?

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?
Had any pain or other problems relating to your back, neck, joints, bones or muscles including arthritis, ankylosing spondylitis, slipped disc, rheumatism or gout?
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)
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).
Had any disease of the skin, including psoriasis or dermatitis?
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.
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).

If you answered Yes, provide more Details about it:

09. Recent and Current Health

9.1. Are you currently pregnant?

9.2. In the last 6 months have you experienced any unintentional or unexplained weight loss?

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).

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?

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?

If you answered Yes, provide more Details about it:

10. Access to Medical Reports Act Declaration – YOUR ELECTRONIC DECLARATION OF CONSENT

I, the applicant, declare that to the best of my knowledge and belief, the information on this form is true and complete. I agree that the terms of this application and declaration, along with any statements made by the life or lives to be assured to the insurer's (or specialist third-party provider's) nurse or medical examiner, together with the insurer’s letter of acceptance, will be deemed to form part of any resultant contracts.

I will inform you immediately of any changes that occur and that would affect my answers before the application is accepted (an application is accepted when a final underwriting decision has been provided).

I understand that failure to do so may result in the contract being declared void, and that a claim for the proceeds may not be paid.

I agree that the insurance company will request a medical certificate from any physician I have consulted regarding my physical or mental health for the reasons mentioned above. I authorize doctors who are asked to issue medical certificates when they receive a copy of my consent.

I am aware that the income benefits I receive could affect the amount of any income support/income based Jobseekers Allowance, should I be eligible for state help.

I authorise my financial adviser to act on my behalf in relation to the matters indicated in this form and to provide information to the Insurer. I request Insurer to act on any such information and, where appropriate, confirm that my financial adviser is able to act on my instructions to provide the information on this form, to apply for a plan and to agree on the commencement date of the plan with the Insurer.

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22 July 2024 11:12 am BST

I_Medical Questionnaire Uploaded by Irina Yanioglova - info@financialagent.co.uk IP 78.48.121.22