Private Medical Insurance Questionnaire Here are some questions that we need from you to get a quote. If you would require more than one member please submit this form again. Name * First Name Last Name Date of Birth In the last 5 years have you had or received treatment for: Heart Condition/Heart Problem * Yes No Stroke * Yes No Diabetes * Yes No Mental Illness * Yes No Other questions Previous Policy was it a company/group policy? * Yes No Do you or anyone to be insured have any treatment, consultations, or diagnostics tests planned or pending * Yes No Medical History Consulted with a specialist, been admitted to hospital or nursing home, or suffered from intermittent or recurrent illness during last 5 years? * Yes No If yes, what was the illness and treatment? What month/year? What was the duration? State of health? Have you seen a medical practitioner in past year? E.g .doctor, physiotherapist, practice nurse? * Yes No If yes, what was the illness and treatment? What month/year? What was the duration? State of health? Have you had any medical condition, disability or health problem not mentioned, e.g. gynaecological, menstrual problems, complications of pregnancy, signs or symptoms of varicose veins, back trouble, joint disorders, joint replacements, foot problems, indigestion or bowel problems, abdominal pain, skin problems, allergies, anxiety, depression or other psychiatric problems trouble with heart, limbs, ears, eyes, urination etc. * Yes No If yes, what was the illness and treatment? What month/year? What was the duration? State of health? Had any GP /specialist consultations, tests, therapies, or treatment (NHS/private) in last 12 months? * Yes No Have appointments planned or pending with a GP, Specialist or a hospital in the future (NHS or Private)? * Yes No Have had any hospital and/or specialist consultations, tests, medication or treatment (NHS or Private) in the last 5 years? * Yes No Have ever had treatment (NHS or Private) for Cancer, Heart Disease, (and circulatory) Psychiatric Conditions or Orthopaedic in the last 5 years? : * Yes No Claims History How many years did the current Private medical policy cover? * Did you claim? * Yes No If Yes, When did you claim? How many claims have you made? Thank you for submitting your Private Medical Insurance Questionnaire. We will get back to you with our findings in the next 24 hours.
