Medical Questionnaire

Please fill in this Standard Medical Questionnaire and submit it back to us. This will allow us to see if you will qualify for Cover.

Note; If there are more than 1 person applying for cover, then both need to fill out the application.

1. Name *

2. Phone *

3. Email *

4. Address

5. Eircode

6. Doctor Name/Practice

7. Doctor Address

8. The length of time you have been with this doctor?

9. Do you smoke or vape ?

Yes

If you smoke, how many cigarettes do you smoke per day?

Please provide details of type and amount of cover, name of insurer and if applicable, reason for special terms.

Medical History

Have you ever had any of the following?

18. Have you ever had any form of Cancer, Tumour, Lymphoma, Hodgkin's disease, Leukaemia, Melanoma or any brain or spinal growth or cysts?

Yes

18-A) When were you diagnosed with this issue? (Month and year)

18-B) Are you:

18-C) When was your last checkup, and what was the outcome?

19. Have you ever had disease or disorder of the heart (including valves) or circulatory system, heart attack, angina, cardiomyopathy, disease of the arteries or peripheral vascular disease?

Yes

19-A) When were you diagnosed with this issue? (Month and year)

19-B) Are you:

19-C) When was your last checkup, and what was the outcome?

20. Have you ever had a stroke, transient ischaemic attack (TIA/mini-stroke), brain haemorrhage, aneurysm, brain injury or surgery to your blood vessels in the brain or neck?

Yes

20-A) When were you diagnosed with this issue? (Month and year)

20-B) Are you:

20-C) When was your last checkup, and what was the outcome?

21. Have you ever had multiple sclerosis, Parkinson’s disease, epilepsy, fit or seizure, Alzheimer’s disease, dementia, cerebral palsy, muscular dystrophy, motor neurone disease or had any other neurological disorder?

Yes

21-A) When were you diagnosed with this issue? (Month and year)

21-B) Are you:

21-C) When was your last checkup, and what was the outcome?

22. Have you ever had bipolar disorder, manic depression, schizophrenia, psychosis or eating disorders, or have you ever required hospital treatment or a referral to a psychiatrist or psychologist as a result of any mental illness?

Yes

22-A) When were you diagnosed with this issue? (Month and year)

22-B) Are you:

22-C) When was your last checkup, and what was the outcome?

23. Have you ever had diabetes, raised blood sugar or sugar in the urine, thyroid problems, goitre or glandular fever?

Yes

23-A) When were you diagnosed with this issue? (Month and year)

23-B) Are you:

23-C) When was your last checkup, and what was the outcome?

24. Have you ever had a positive test for HIV/AIDS or Hepatitis B or C, or are you awaiting the results of such a test?

Yes

24-A) When were you diagnosed with this issue? (Month and year)

24-B) Are you:

24-C) When was your last checkup, and what was the outcome?

25. Have you ever had and issues relating to raised blood pressure, raised cholesterol, chest pain or irregular heart beat?

Yes

25-A) When were you diagnosed with this issue? (Month and Year)

25-B) Are you:

25-C) When was your last checkup, and what was the outcome?

26. Have you ever had depression, anxiety, stress, insomnia, chronic fatigue syndrome, eating disorders or have you been referred to a psychiatrist or hospital clinic as a result of any mental illness?

Yes

26-A) When were you diagnosed with this issue? (Month and year)

26-B) Are you:

26-C) When was your last checkup, and what was the outcome?

27. Have you ever had any numbness pins and needles, optic neuritis, double/blurred vision, tremor, tingling, muscle weakness, loss or reduced power in limbs, persistent tiredness or fatigue? Please answer ‘yes’ whether you have been seen by a doctor for any other these listed issues?

Yes

27-A) When were you diagnosed with this issue? (Month and year)

27-B) Are you:

27-C) When was your last checkup, and what was the outcome?

28. Have you ever had any issues relating to any form of arthritis, gout, joint-or ligament pain or neck, back, spine or muscle pain or stiffness?

Yes

28-A) When were you diagnosed with this issue? (Month and year)

28-B) Are you:

28-C) When was your last checkup, and what was the outcome?

29. Have you ever had Any disorder affecting your ears or hearing, or your eyes or vision that is not wholly corrected by spectacles or lenses?

Yes

29-A) When were you diagnosed with this issue? (Month and year)

29-B) Are you:

29-C) When was your last checkup, and what was the outcome?

30. Have you ever had tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed in appearance or become painful? Please answer ‘yes’ whether you have been seen by a doctor or not.

Yes

30-A) When were you diagnosed with this issue? (Month and year)

30-B) Are you:

30-C) When was your last checkup, and what was the outcome?

31. Have you ever had any of the following;

Asthma, bronchitis, sarcoidosis, emphysema or any other disorder affecting your lungs or breathing?

Yes

31-A) When were you diagnosed with this issue? (Month and year)

31-B) Are you:

31-C) When was your last checkup, and what was the outcome?

32. Have you ever had any disorder of the digestive system, liver, stomach, pancreas or bowel (including any ulcer, hepatitis, colitis, Crohn's disease or Barrett’s osophagus)?

Yes

32-A) When were you diagnosed with this issue? (Month and year)

32-B) Are you:

32-C) When was your last checkup, and what was the outcome?

33. Have you ever had any of the following?

Haemochromatosis, anaemia, vitamin b12 deficiency, clotting disorders or any other blood disorders?

Yes

33-A) When were you diagnosed with this issue? (Month and year)

33-B) Are you:

33-C) When was your last checkup, and what was the outcome?

34. Have you ever had any disorder of the kidney, bladder or prostate, including blood or protein in the urine or raised PSA (Prostate Specific Antigen)?

Yes

34-A) When were you diagnosed with this issue? (Month and year)

34-B) Are you:

34-C) When was your last checkup, and what was the outcome?

35. Have you ever been regularly prescribed medication or treatment lasting for a period of 4 consecutive weeks or more, or have you been under review from your doctor or a medical professionals? You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy.

Yes

35-A) When were you diagnosed with this issue? (Month and year)

35-B) Are you:

35-C) When was your last checkup, and what was the outcome?

Recent Medical Issues

36. Apart from anything you have already told us about, during the last 3 years have you:

36(a) Been referred to a specialist, undergone or been advised to have any tests or investigations? For example: Abnormal smear or mammogram, biopsy, colonoscopy, scans or blood tests. You do not need to tell us about investigations which were purely for pregnancy, infertility or simple fractures.

Yes

36(b) Are you awaiting referral, investigations, results or treatment, for anything else or do you have any other symptoms for which you have not yet sought medical advice? For example: Bleeding from the bowels or change in bowel habit, persistent cough, weight loss, onset of fits or seizures, dizziness, blackouts or fainting.

Yes

36(c) Have any of your natural parents, brothers or sisters ever been diagnosed with or died from any of the following before age 60? Heart Attack or Angina, Cancer (including Leukemia or Lymphoma), Multiple Sclerosis, Muscular Dystrophy, Motor Neuron Disease, Cardiomyopathy, Poly-cystic Kidney Disease, Familial Colon Polyps, Stroke, Diabetes, Huntington's Disease, Alzheimer’s Disease, Parkinson’s Disease, Haemochromatoasis.

Yes

36(d) Please give details of the relative(s) in question;

Type of Relative

Condition

Age of Diagnosis

If you have had any tests or check-ups as a result of a relative’s medical condition, please give details here. In line with the Disability Act 2005, the results of any genetic tests should not be disclosed.

37. COVID-19

Have you ever been diagnosed with COVID-19?

Yes

Have you experienced any COVID 19-like symptoms in the last 3 months?

Yes

The date you were diagnosed?

What symptoms did you have?

Did you attend a hospital?

Are you fully recovered?

38. Are two people applying for cover? ( You and your partner )

Yes

2nd Person Medical Information

Please fill out the following information for the second person on the policy:

1. Name of the Person *

Phone Number

Email Address

2. Do you smoke or vape (For 2nd Person)?

Yes

If you smoke, how many cigarettes do you smoke per day (For 2nd Person)?

4. What is your weight (For 2nd Person)?

5. How many units (1 pint/1 glass of wine = 2 units) of alcohol do you consume in an average week (For 2nd Person)?

6. Have you ever been given medical advice to reduce your alcohol intake (For 2nd Person)?

Yes

7. Have you ever used illegal/recreational drugs (For 2nd Person)?

Yes

8. Do you intend to take part in any hazardous sports? e.g. aviation, motorsports (For 2nd Person)

Yes

9. Have you ever had an application for Life, Specified Serious illness or Income Protection cover declined, postponed or had special terms-applied to it (For 2nd Person)?

Yes

Please provide details of type and amount of cover, name of insurer and if applicable, reason for special terms (For 2nd Person).

Name & address of current doctor (For 2nd Person)

2nd Person Medical Hisory

1. Any form of cancer, tumour, lymphoma, Hodgkin's disease, leukaemia, melanoma or any brain or spinal growth or cysts (For 2nd Person)?

Yes

1-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

1-B) Are you: (For 2nd Person)

1-C) When was your last checkup, and what was the outcome (For 2nd Person)?

2. Raised blood pressure, raised cholesterol, chest pain or irregular heart beat (For 2nd Person)?

Yes

2-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

2-B) Are you: (For 2nd Person)

2-C) When was your last checkup, and what was the outcome (For 2nd Person)?

3. Numbness. pins and needles, optic neuritis, double/blurred vision, tremor, tingling, muscle weakness, loss or reduced power in limbs, or persistent tiredness or fatigue? Please answer ‘yes’ whether you have been seen by a doctor or not (For 2nd Person).

Yes

3-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

3-B) Are you: (For 2nd Person)

3-C) When was your last checkup, and what was the outcome (For 2nd Person)?

4. Any form of arthritis, gout, joint-or ligament pain or neck, back, spine or muscle pain or stiffness (For 2nd Person)?

Yes

4-A) When were you diagnosed with this issue? (Month and year)

4-B) Are you: (For 2nd Person)

4-C) When was your last checkup, and what was the outcome (For 2nd Person)?

5. Any disorder affecting your ears or hearing, or your eyes or vision that is not wholly corrected by spectacles or lenses (For 2nd Person)?

Yes

5-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

5-B) Are you: (For 2nd Person)

5-C) When was your last checkup, and what was the outcome (For 2nd Person)?

A tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed in appearance or become painful? Please answer ‘yes’ whether you have been seen by a doctor or not (For 2nd Person).

Yes

6-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

6-B) Are you: (For 2nd Person)

6-C) When was your last checkup, and what was the outcome (For 2nd Person)?

7. Have you ever had any of the following?

Asthma, bronchitis, sarcoidosis, emphysema or any other disorder affecting your lungs or breathing (For 2nd Person)?

Yes

7-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

7-B) Are you: (For 2nd Person)

7-C) When was your last checkup, and what was the outcome (For 2nd Person)?

8. Regularly been prescribed medication or treatment lasting for a period of 4 consecutive weeks or more, or have you been under review from your doctor or a medical professionals? You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy (For 2nd Person).

Yes

8-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

8-B) Are you: (For 2nd Person)

8-C) When was your last checkup, and what was the outcome (For 2nd Person)?

9. Any disorder of the digestive system, liver, stomach, pancreas or bowel (including any ulcer, hepatitis, colitis, Crohn's disease or Barrett’s osophagus) (For 2nd Person)?

Yes

9-A) When were you diagnosed with this issue? (Month and year)

9-B) Are you: (For 2nd Person)

9-C) When was your last checkup, and what was the outcome (For 2nd Person)?

10. Have you ever had any of the following?

Haemochromatosis, anaemia, vitamin b12 deficiency, clotting disorders or any other blood disorders (For 2nd Person)?

Yes

10-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

10-B) Are you: (For 2nd Person)

10-C) When was your last checkup, and what was the outcome (For 2nd Person)?

11. Any disorder of the kidney, bladder or prostate, including blood or protein in the urine or raised PSA (Prostate Specific Antigen) (For 2nd Person)?

Yes

11-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

11-B) Are you: (For 2nd Person)

11-C) When was your last checkup, and what was the outcome (For 2nd Person)?

2nd Person Recent Medical Issues

12. Apart from anything you have already told us about, during the last 3 years have you:

12(a) Been referred to a specialist, undergone or been advised to have any tests or investigations? For example: Abnormal smear or mammogram, biopsy, colonoscopy, scans or blood tests. You do not need to tell us about investigations which were purely for pregnancy, infertility or simple fractures (For 2nd Person).

Yes

12(b) Are you awaiting referral, investigations, results or treatment, for anything else or do you have any other symptoms for which you have not yet sought medical advice? For example: Bleeding from the bowels or change in bowel habit, persistent cough, weight loss, onset of fits or seizures, dizziness, blackouts or fainting (For 2nd Person).

Yes

2nd Person Family History

13. Please fill out the family medical history questions below for the 2nd person on this policy.

Have any of your natural parents, brothers or sisters ever been diagnosed with or died from any of the following before age 60? Heart Attack or Angina, Cancer (including Leukemia or Lymphoma), Multiple Sclerosis, Muscular Dystrophy, Motor Neuron Disease, Cardiomyopathy, Poly-cystic Kidney Disease, Familial Colon Polyps, Stroke, Diabetes, Huntington's Disease, Alzheimer’s Disease, Parkinson’s Disease, Haemochromatoasis (For 2nd Person).

Yes

23. Please give details of the relative(s) in question;

Type of Relative (For 2nd Person)

Condition (For 2nd Person)

Age of Diagnosis (For 2nd Person)

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