Medical Questionnaire Form
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1PERSONS TO BE COVERED
SURNAME
FIRST NAME
DATE OF BIRTH
SEX
M F
M F
M F
M F
MEDICAL QUESTIONNAIRE – ALL QUESTIONS TO BE ANSWERED FULLY
(GOLD, SILVER, HOSPITALISATION & COMFORT AND LUXURY TOP-UP INSURANCE)
Sensitive medical information will need to be processed in order to provide cover. Please obtain the consent of any other people named before disclosing this. If you
consider that information relating to your state of health or that of any other person to be covered should remain confidential, please send it in a sealed envelope for the
attention of the Consulting Doctor. Please use a separate piece of paper if there is insufficient room for your reply.
1
Height
………………….……M
………………………M
………………….……M
……………….……M
Weight
……………….…...…Kg
………………...……Kg
……….………………Kg
…….………………Kg
2
Blood pressure
/
/
/
/
Systolic / Diastolic
……...
.…...… mmHg
……...
.…..… mmHg
……...
.…...… mmHg
….....
..….. mmHg
COMPULSORY
3
Do you smoke?
YES
NO
YES
NO
YES
NO
YES
NO
4
Have you had any medical
YES
NO
YES
NO
YES
NO
YES
NO
consultation/investigations/treatment in the
……………………….
……………………….
………………………….
………………………….
last 6 months or is any planned?
……………………….
……………………….
………………………….
………………………….
If so, please provide full details?
5
Have you ever been hospitalised or had
YES
NO
YES
NO
YES
NO
YES
NO
surgery?
……………………….
……………………….
………………………….
………………………….
If so, please provide date and reason for
……………………….
……………………….
………………………….
………………………….
hospitalisation
6
Do you need to be hospitalised or have
YES
NO
YES
NO
YES
NO
YES
NO
surgery?
……………………….
……………………….
………………………….
………………………….
If so, please provide date and reason for
……………………….
……………………….
………………………….
………………………….
hospitalisation
Have you received or are you currently
7
YES
NO
YES
NO
YES
NO
YES
NO
receiving regular medical treatment?
……………………….
……………………….
………………………….
………………………….
If so, please provide details
……………………….
……………………….
………………………….
………………………….
8
Do you suffer from a chronic or long-term
YES
NO
YES
NO
YES
NO
YES
NO
illness?
……………………….
……………………….
…………………….
………………………….
If so, please provide details
……………………….
……………………….
………………………….
………………………….
9
Do you have any aftereffects from an
YES
NO
YES
NO
YES
NO
YES
NO
accident, illness or disability?
……………………….
……………………….
………………………….
………………………….
If so, please provide details
……………………….
……………………….
………………………….
………………………….
10
Have you been or are you currently unable to
YES
NO
YES
NO
YES
NO
YES
NO
work for medical reasons?
……………………….
……………………….
………………………….
………………………….
If so, please provide details
……………………….
……………………….
………………………….
………………………….
11
Do you have any dentures, dental implants or
YES
NO
YES
NO
YES
NO
YES
NO
orthodontic work planned within the next 12
……………………….
……………………….
………………………….
………………………….
months? If so, please attach a quote.
……………………….
……………………….
………………………….
………………………….
(GOLD, SILVER & LUXURY)
12
Are you pregnant?
YES
NO
YES
NO
YES
NO
YES
NO
Signed in ………………………… on the ………………………….…
WARNING: You are advised to complete this proposal form
yourself. Where this is not possible, you are advised not to sign
SIGNATURE preceded by the text ‘read and approved’
the proposal form until you have read and agreed that the answers
given to the questions are accurate and complete. You should also
state who completed the form on your behalf:
.……………………………………...……………………………………
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