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Step
1
of
2
50%
Protection Questionnaire
Lifestyle, Residency, Travel & Sports
Smoking/Vaping
What is your height?
*
What is your weight?
*
What is your trouser or dress size?
*
Smoking/Vaping
Do you smoke?
*
Yes
No
How many?
*
Recreational Drugs
Have you taken recreational drugs in the last 5 years?
*
Yes
No
Alcohol
How often do you drink alcohol?
*
When you drink how much is typical?
*
Have you ever attended an alcohol support group?
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Yes
No
Have you ever had liver damage?
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Yes
No
Have you been told by a health professional to drink less?
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Yes
No
HIV
Have you tested HIV positive?
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Yes
No
Sport & Activity
Do you participate in any of these sports and activities regularly or any other extreme sport?
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Caving, Flying
Hang gliding
Car Sport
Motor cycle sport
Mountaineering
Parachuting
Power boat racing
Underwater diving
Sailing
Other
None of the above
If yes, please explain below
*
Your Doctor
Doctors Name
*
Surgery Name & Address
*
Contact number
Do you have any other life or critical illness policies?
*
Yes
No
If yes, who are they with?
*
Have you had any injuries or treatments, received any treatments or been hospitalised in the last 5 years?
*
Yes
No
If yes, please explain below:
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Medical History
Health questions
Have you ever suffered from any of the following health conditions:
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Diabetes/ heart condition?
Stroke/ mini stroke?
Cancer, leukaemia or melanoma?
Cyst/ tumour on brain or spine?
Any neurological conditions?
Mental illness, anorexia or bulimia?
None of the above
If yes, please specify
*
Health questions (last 5 years)
In the last 5 years, have you suffered from any of the following health conditions:
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Blood pressure?
Kidney / bladder/prostate problems?
Stomach, oesophagus and/or bowel problems?
Liver, gall bladder or pancreas?
Breathing, asthma emphysema?
Gout, arthrites, sciatica?
Anxiety or depression that involved stain hospital?
Growth, lump or polyp removed?
Chest pain, memory loss or dizziness?
None of the above
If yes, please specify
*
Health questions (other)
Have you ever seen anyone about any of the following other health conditions:
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Removing a mole or freckle?
Thyroid?
Hearing?
Sight (not related to glasses)?
Gynaecological?
Illness/disability keeping you off work for two weeks or more?
Medical condition you have been treated for for over 4 weeks?
Been referred for ECG, biopsy scan?
Unexplained bleeding or weight loss?
Have you been told to see a doctor in next 3 weeks?
None of the above
If yes, please specify
*
Family History
Has anyone in your immediate family ever suffered from any of the following health conditions:
*
Heart attack angina stroke type 2 diabetes?
Breast cancer?
Ovarian cancer?
Bowel cancer?
Other cancer (specify)?
Multiple Sclerosis?
Motor Neurone?
Alzheimers?
Parkinsons?
Other
None of the above
If yes, please specify details including their age at the time
*
Have you had any injuries or treatments, received any treatments or been hospitalised in the last 5 years?
*
Yes
No
If yes, please explain below
*
Is there any other information that you feel is relevant?
*
Yes
No
If yes, please explain below
*
Coronavirus (COVID-19)
Have you ever been treated in hospital due to Coronavirus (COVID-19)?
*
Yes
No
If yes, please explain below
*
In relation to Coronavirus, within the last 30 days have you:
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Experienced symptoms of a cough, breathing difficulties, a high temperature or fever, a loss or change in taste or smell; or
Been diagnosed with Coronavirus (COVID-19); or
Self-isolated for any other reason or had contact with someone who's been confirmed or suspected to have Coronavirus (COVID-19)
None of the above
If yes, please explain below
*
In the last three months have you had any new symptoms of fatigue, persistent tiredness, muscle aches, or joint pains even if you have not consulted a doctor?
*
Yes
No
If yes, please explain below
*
Confirmation
Client Name:
*
Date:
*
MM slash DD slash YYYY