sepiHestn/utesye/Pevausinumrceoetsi QE (Cs Health Detai “ilmandlatory fies, marked with an asterixt), must be completed before the quote can be calculated. 1 weight) | insort weight vm ‘Smoking Status Insert Year of Smoking Insert No.of CigaretteHealth Detail Questions © o/9completed 3a. Do you have a usual doctor? Has anyone in your family (living or dead) ever suffered from diabetes, heart lisease, high bleod pressure, stroke, kidney lisease (including polycystic kidney disease), mental disorder, hepatitis B, hepatitis C, cancer, Alzheimer's / Parkinson's disease or any other hereditary disease? Do you currently have, or ever had in the past, any symptoms, or complaints, or investigation.or treatment, or receiving advice for: Impaired sight, hearing or speech or any disease or disorder of the eyes, ers, ‘nose, mouth or throat, oesophagus: persistent hoarseness or cough, shortness of breath or coughing of blood: asthma, bronchitts, tuberculosis, pneumonia, sleep apnoea or other lung or respiratory disorder?Step 3: Health / LifeStyle / Previous Insurance Detail 3b. Fits epilepsy, numbness tinglings of limb and/or face, involuntary shaking, ‘weakness of imb, recurrent dizziness or headaches migraines fainting, multiple sclerosis, paralysis, mental or nervous disorder including anxiety, depression, panic attacks, chronic fatigue or attempts of suicide), Parkinson'sAlzheimers isease, dementia or any abnormalities of the brain? Se. Chest pain discomfort or tightness; palpitations, heart attack, high blood pressure, stroke, rheumatic fever, heart valve disorder, heart murmur; raised cholesterol or ay disease or disorder ofthe heart or blood vessels; anaemia, ‘thalassaemia, haermapbhilia or any disorder of the blood? Sd. Jaundice, being a Hepatitis ® of C carrer gastritis stomach or duodenal ulcer or ‘any disorder of the stomach, intestines, Iver, gallbladder, pancreas or digestive system? ‘Se, Sugar, blood or protein in urine, urinary stone or infection, urinary reflux, urinary Incontinence: or any disease or disorder of the urinary system including kidney. bladder, prostate or reproductive organ or sexually transmitted disease (ea, syphilis, gonorrhea) including genital sores or cischarges?‘Step 3: Health / Lifestyle / Previous Insurance Detail Bf, Diabetes, abnormal blood sugar. goltre thyrokd or other endocrine disorder? ‘Cancer {including leukaemia, lymphoma, melanoma), tumour, growth, cyst enlarged glands or skin infections, Systemic Lupus Erythematosus (SLE), Kawasakl disease or any other disorder of the immune systern? Rheumatism, arthritis, osteoporesis fracture, gout or disorder of the muscles, Skin or other soft tissues, ones, neck, spine, back or Joins; sciatica, deformity, lameness or amputation? ‘Are you currently considering or receiving medical treatment or under medical ‘care of any kine or ever had any liness/njury or disability lasting or requiring {eatment or absence from work for more than 7 days; or been advised or referred to or admitted to a hospital or medical facility or specialist? Have you ever had or been advised or intend! to undergo any investigations) Screening test including but not limited to angiogram, echocardiogram. ‘lectrocardiogram, X-ray, ultrasound. CT/MRUPET scan, blood er urine test, biopsy4c. Areyou currently experiencing any symptoms or complaints which you have not consulted a doctor? 5. Have you or your spouse/partner ever been tested for, told to have, received of expect to receive medical ecvice. counseling or treatment in connection with Hiv, AIDS, AIDS related complex or any other AIDS related condition, or at any time in the past months, had any ofthe following symptoms for more than one. ‘week continuousl-unexplained recurrent or persistent fever of fatigue, Unexplained weight loss, enlarged lymph nodes, chronie or recurrent diarrhea, Unusual skin lesions? rs G2) &® ceo se‘Step 3: Health / LifeStyle / Previous Insurance Detail 6c. 6d. 62, Have you had any disease or disorder of the breast, cervix uteri, uterus or ovaries Including breast ump, breast or ovarian cyst, carcinoma in-sits fibroid, pols, Post-coital bleeding. cancer or growth? Have you over had Pap Smear, mammogram, biopsy, ultrasound of the breast ‘or pelvis, cone biopsy or colposcopy or any ether gynaecological investigations ‘which was found! to be abnormal, of you were advised to repeat within 6 months? Have you had any complications during pregnancy or childbirth (og. gestational diabetes, gestational hypertension, pre-eclampsia/eclampsia, ectopic pregnancy, Stillbirth, miscarriage, disseminated intravascular coagulation, abruptio. placentae, of amniotic fluid embolisml:or any of your chikiren ever suffered from, spina bifida, Down's syndrome, cleft palate. congenital heart dicease, anal atresia, arial septal defect, congenital cataract, congenital deafness, congenital diaphragmatic hernia, infantile hydrocephalus, tetralogy of fallot transposition of ‘great vessels, runcus arteriosus, ventricular septal defect, or any other congenital defects/abnormality? Gemp «© = OU CGE =) (G=9)