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Health Questionnaire

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Health Questionnaire

Please provide your medical and health conditions as well as current insurance policy details by completing the form below.

Before you supply any personal details to us via the contact us page on this website please read our customer privacy notice document that can be found at the bottom of this website under Privacy Policy link. This notice sets out how we will process your personal data in line with the General Data Protection Regulations. Once you have read the customer privacy notice, please tick to confirm that you have read it and that you agree to Mortgage Matters (Hayes) processing your personal information for the purpose of contacting you. We will not use the details you provide us in the contact page to market to you.

Health Questionnaire

1. First Name

Last Name

2. Date of Birth

3. Address

Address Line 1

Address Line 2

City

County

Postal Code

Country

4. Phone/Mobile

5. Email

6. Please provide the name, address and postcode of your doctor, for where you are registered

7. Please provide the telephone number of your doctors surgery.

8. How many times have you visited your GP in the last 12 months?

9. What is your height?

10. What is your weight?

11. Please give your UK trouser waist or dress size

12. Have you smoked or used any form of tobacco / nicotine replacement products in the last 12 months?

Please give details below.

13. In an average week, how many alcoholic drink would you consume?

14. Have you ever been advised by a Doctor to reduce your alcohol intake?

Please give details below.

15. Have you ever taken recreational drugs?

Please give details below.

16. Do you have any current life insurance policies?

Please give as much detail as possible about your current policies.

17. Will you be keeping the current policies upon starting the new policy?

18. Have you ever been declined life insurance?

Please give details as to why you have been declined cover previously.

19. Do you ride a motorcycle, scooter or moped on the roads?

20. During the last 5 years, have you ever travelled abroad to another country for more than 30 days?

Please give details below.

21. Do you intend to travel out of the country for more than 30 days per time in the future?

Please give details below.

22. How often do you exercise for 30 minutes or more per week?

23. Have you ever suffered from OR been diagnosed with Asthma, chronic obstructive pulmonary disease (COPD), or any other condition effecting your longs or breathing (other than hay fever)?

Please give us more details about this condition.

24. Have you ever suffered from OR been tested for any of the following - Any form of Cancer? Leukemia? Hodgkin's disease? Tumour? Lymphoma? Or Melanoma?

Please provide us with further details to your answer above giving as much detail as possible.

25. Have you ever suffered from OR been tested for any of the following - Heart disorder? Heart attack? Angina? Cardiomyopathy? Heart murmur?

Please provide us with further details to your answer above giving as much detail as possible.

26. Have you ever suffered from OR been tested suffered from OR been tested for any of the following - Stroke? Brain haemorrhage? Transient ischaemic attack? Brain injury? Brain tumour?

Please provide us with further details to your answer above giving as much detail as possible.

27. Have you ever suffered from OR been tested for any of the following - Multiple sclerosis? Parkinson's disease? Paralysis? Alzheimer's disease? Dementia? Cerebral palsy?

Please provide us with further details to your answer above giving as much detail as possible.

28. Have you ever suffered from OR been tested for any of the following - Numbness? Loss of feeling? Tingling? Tremor? Temporary loss of muscle power?

Please provide us with further details to your answer above giving as much detail as possible.

29. Have you ever suffered from OR been tested for any of the following - Blindness? Blurred or disturbed vision?

Please provide us with further details to your answer above giving as much detail as possible.

30. Have you ever suffered from OR been tested for any of the following? Diabetes? Sugar in the urine?

Please provide us with further details to your answer above giving as much detail as possible.

31. Have you ever suffered from any mental illness that has required hospital treatment or referral to a psychiatrist?

Please provide us with further details to your answer above giving as much detail as possible.

32. In the last 5 years, have you been diagnosed with or had symptoms of, any of the following - A lump or growth of any kind, any mole or freckle that had bled, become painful, changed colour or increased in size? Chest pain, irregular heartbeat?

Please provide us with further details to your answer above giving as much detail as possible.

33. In the last 5 years, have you been diagnosed with or had symptoms of, any of the following? Disorder of the digestive system, liver, stomach, pancreas or bowel, including ulcers, hepatitis, colitis or Crohn's disease? Blood disorder or anemia?

Please provide us with further details to your answer above giving as much detail as possible.

34. FEMALE ONLY: In the last 5 years, have you been diagnosed with or had symptoms of, any of the following - Abnormal cervical smear, mammogram or had a biopsy of the breast, cervix or uterus?

Please provide us with further details to your answer above giving as much detail as possible.

35. MALE ONLY: In the last 5 years, have you been diagnosed with or had symptoms of, any of the following? - Prostate enlargement or raised PSA (prostate specific antigen)?

Please provide us with further details to your answer above giving as much detail as possible.

36. Other than the medical conditions mentioned previously, have you? Had or been advised to have any medical investigations, scans or blood tests? Received any form of medical attention at a hospital as an inpatient or outpatient?

Please provide us with further details to your answer above giving as much detail as possible.

37. Are you currently experiencing any symptoms or disorders for which you haven't consulted a Doctor?

Please give details of your symptoms.

38. Are you currently taking drugs, medicines or tablets or receiving any other treatment not already mentioned?

Please can you provide details of what you are taking.

39. Are you currently awaiting a medical consultation or hospital appointment, or awaiting results of any tests?

Please give details of appointments or tests taken.

40. Have you ever tested positive for HIV, hepatitis B or C or are you awaiting the results of a test? (if the result was negative, the fact that you have had a HIV test will not affect your application for insurance)

Please provide details of any tests & the results.

41. Within the last 5 years, have you been exposed to risk of HIV infection? (This could have been through unsafe sex, intravenous drug use, blood transfusions or surgery outside of the EU)

Please give details of the risks posed.

42. Within the last 5 years, have you tested positive or been treated for any disease which was transmitted sexually?

Please provide further details of any disease.

43. Before aged 60, have any of your parents, brother or sisters been diagnosed with any of the following - Alzheimer's disease? Cancer? Diabetes? Haemochromatosis? Heart disease? Huntington's disease? Kidney failure? or polycystic Kidney Disease?AC

Please provide us with further details to your answer giving us much detail as possible.

44. Have you ever been banned from driving?

45. Is your father still alive?

What age is your Father now?

At what age did your Father die? (If Applicable)

46. Is your Mother still alive?

What age is your Mother now?

At what age did your Mother die? (if applicable)

47. If you have answered yes or ticked any medical conditions above, please provide more detail below about any/each:

I AGREE WITH THE FOLLOWING TERMS:

To the best of my knowledge, all the information I have provided in this form are true and correct.

I have read and agree to the Terms and Conditions and Privacy Policy.

We Will Help You Every Step Of The Way

From first time buyer to buy to let or let to buy, from Life insurance to Mortgage Protection Insurance or Building and Content Insurance, from re-mortgaging your existing property to protecting your business, we will always be at your reach

Mortgage Matters (Hayes) is an Appointed Representative of Rosemount Financial Solutions (IFA) Ltd which is authorised and regulated by the Financial Conduct Authority (FCA). Entered on the FCA Register (https://register.fca.org.uk/) under reference 535515.

Registered as a Limited Company in England & Wales No 11271116. Registered Address: 9 Bannister Close, Slough SL3 7DP.

The information contained within this website is subject to the UK regulatory regime, and is therefore targeted at consumers based in the UK.

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