Arthritis questionnaire *

* To be filled in by the Life Assured

Full name:
Contract No:
1 Which form of arthritis do you suffer from?
eg Rheumatoid arthritis, osteoarthritis, etc
______________________________________________________
2 When was this condition first diagnosed?
______________________________________________________
3 Have you had any x-rays or other investigations? YES / NO
If YES, please provide details including dates of investigations and results.
______________________________________________________
4 Regarding your symptoms/disability:
a Please describe your symptoms.
______________________________________________________
b When did symptoms first occur?
______________________________________________________
c How frequently do symptoms occur? eg how often in the last 12 months
______________________________________________________
d Which of your joints are affected?
______________________________________________________
e Are your activities restricted in any way? YES / NO
If YES, please provide details.
______________________________________________________
f Do you use a walking stick or other mobility aids? YES / NO
If YES, please provide details.
______________________________________________________
5 Have you had an operation for this condition or is an
operation being considered? YES / NO
If YES, please provide date(s) and full details including names of hospital and
consultant/surgeon.
______________________________________________________
6 Please provide details of your treatment. Include names of medication (eg Brufen,
Indocid, Naprosyn etc), dosage and how often taken. Include details of any injections:
a Currently
________________________________
b In the past
________________________________
c Have you ever taken steroids? eg Betnesol, Ledercort,Prednesol etc YES / NO
If YES, please provide details.
________________________________
7 Regarding the monitoring of your condition:
a Who is in charge of your follow-up?

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b How often do you attend for follow-up?
______________________________________________________

c When was your last consultation?

______________________________________________________

8 Have you lost significant time (eg weeks) off work with this condition? YES / NO
If YES, please provide details including dates and duration of time off work.
______________________________________________________
______________________________________________________

9 Please provide any additional information on your condition which you feel will be
helpful in processing your application.
______________________________________________________
______________________________________________________

I declare that the answers I have given are, to the best of my knowledge, true and that I have
not withheld any material information that may influence the assessment or acceptance of
this application.
I agree that this form will constitute part of my application for life assurance and that failure
to disclose any material fact known to me may invalidate the contract.

Signature of Life Assured

__________________

Date: _____________

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