Protection Health Questionnaire

Section 1

Personal details

* Required information

Title * Gender * First Name *Middle Name(s) Surname * Email address *Mobile number *

Date of Birth *

Address *

Section 2

Your doctor's details

Doctor's Name *Doctor's Tel No. *Surgery Address *

Section 3

Work, total cover & travel

Job Title *

How many business miles do you do in a year? *

Please do not include travel to and from your place of work.

Zero Miles More

How many miles?

Do you work in any of the following occupations or environments? *

During the last 5 years have you spent more than 90 consecutive days in Africa, the Caribbean, Russia, Thailand or Ukraine? *

During the next 2 years do you intend to spend more than 30 consecutive days outside the UK? *

No Please move on to the next question I will be staying within the European Union, United States of America, Canada, Australia or New Zealand Countries outside the European Union, United States of America, Canada, Australia or New Zealand

Which one(s)?Please tell us which you intend to travel toHow long are you leaving the UK for?If you are leaving the UK permanently when do you plan to go?

Section 4

Mental Health

In the last 5 years have you suffered from any of the following? *You answered YES to the question above. Please provide additional information such as, dates of any specialists you might have spoken to and when, in the box below:

Have you ever suffered with any of these conditions? *You answered YES to the question above. Please provide additional information such as, dates of any specialists you might have spoken to and when, in the box below:

Have you ever? *

No Please move on to the next question Tried to take your own life Had thought about taking your own life Intentionally harmed yourself Had thoughts about harming yourself

You answered YES to the question above. Please provide additional information such as, dates of any specialists you might have spoken to and when, in the box below:

Section 5

Hazardous activities

Not including your occupation, do you regularly take part in any of the activities listed or do you intend to do so within the next 6 months? *

Section 6

HEALTH AND LIFESTYLE

Which of the following best describes your smoker status *

Smoker status includes cigarettes, vaping, nicotine products, e-cigarettes, or nicotine replacement products

I’ve never smoked I’ve smoked in the last 12 months I haven’t smoked in the last 12 months, but I have smoked in the previous 5 years I used to smoke but gave up more than 5 years ago

Month stopped smokingYear stopped smoking

Please provide the following height and weight details *

Imperial Metric

This information will be used to obtain our estimated BMI (Body Mass Index)

Height – first measurementHeight – second measurementWeight – first measurementWeight – second measurement

Waist size Dress size

Waist sizeDress size

During the last 5 years have you used any of the drugs listed? *

There are no 'legal implications' in answering yes to this question.

No Please move on to the next question Recreational drugs other than cannabis, for example Cocaine, Ecstasy, Heroin Methadone Anabolic steroids not prescribed by a doctor

Have you ever tested positive for HIV, or awaiting test results? *

A negative HIV test result won't, by itself, have any effect on your acceptance terms for insurance.

No Awaiting results of HIV test Tested positive for HIV

How often do you drink alcohol? *

Tick only one box

NEVER Please move on to the next question Monthly Weekly Daily

How many drinks do you consume on average in this time period?

Please tick any of the following alcohol related questions if they apply to you?

Have you ever been referred to or been seen by an alcohol specialist? Have you ever attended or been advised to attend an alcohol support group? Have you ever been told that you have any liver damage, which may have been caused by alcohol? Have you ever been told by a health professional that you should reduce the amount of alcohol you're consuming?

If you answered, "YES" to any of the questions above, please provide details in the box below including the date you last saw your consultant, if you have a follow up appointment planned, if you have any further tests scheduled or if you have been discharged from treatment:

Have you ever had any of the following? *

Heart condition, for example angina, heart attack, heart valve problem, heart surgery *

Stroke, mini stroke, transient ischaemic attack (TIA), brain haemorrhage or surgery to your blood vessels *

Cancer, Hodgkin lymphoma, Non-Hodgkin lymphoma, leukaemia or a melanoma *

Cyst, growth or tumour in either your brain or spine *

Any neurological condition or visual disturbance, for example epilepsy, multiple sclerosis, muscular dystrophy, cerebral palsy, motor neurone disease, Parkinson's disease, optic neuritis *

Been admitted overnight to hospital or referred to a psychiatrist for mental illness, anorexia or bulimia *

If you answered, "YES" to any of the questions above, please provide details in the box below including the date you last saw your consultant, if you have a follow up appointment planned, if you have any further tests scheduled or if you have been discharged from treatment:

During the last 5 years have you seen a health professional for any of the following? *

Raised blood pressure, raised cholesterol or condition affecting blood or blood vessels, for example anaemia, excess sugar in the blood, blood clot or deep vein thrombosis *

Any condition affecting your kidneys, bladder or prostate, for example blood or protein in the urine, kidney or bladder stones *

Any condition affecting your stomach, oesophagus or bowel, for example Crohn's disease, ulcerative colitis *

Any condition affecting your gall bladder, liver or pancreas, for example hepatitis, fatty liver *

Any condition affecting your lungs or breathing, for example asthma, emphysema, sleep apnoea, sarcoidosis *

Lupus, fibromyalgia, gout or any type of arthritis, neck, back, spine or joint trouble, for example rheumatoid arthritis, sciatica *

Anxiety, depression or any mental illness that's required treatment or counselling, or chronic fatigue syndrome *

A growth, lump, polyp or tumour of any kind *

Chest pain, palpitations or irregular heartbeat, paralysis, numbness, persistent tingling or pins and needles, tremor or facial pain other than dental pain, memory loss, dizziness or balance problems *

If you answered, "YES" to any of the questions above, please provide details in the box below including the date you last saw your consultant, if you have a follow up appointment planned, if you have any further tests scheduled or if you have been discharged from treatment:

During the last 5 years have you seen a health professional for any of the following? *

A mole or freckle *

Any condition affecting your thyroid *

Any condition affecting your ears or hearing, for example Meniere's disease, deafness *

Any condition affecting your eyes or vision, not wholly corrected by spectacles, lenses or laser treatment, for example cataract, blindness *

Any gynaecological condition for which you've not yet been discharged from follow up, or a cervical smear requiring further investigations? (Applicable to females only) *

If you're applying for Income Protection Benefit: Any other illness, injury or disability that's kept you off work for a continuous period of 2 weeks or more, for example stress, headaches, trapped nerve? (excludes colds and flu) *

If you answered, "YES" to any of the questions above, please provide details in the box below including the date you last saw your consultant, if you have a follow up appointment planned, if you have any further tests scheduled or if you have been discharged from treatment:

During the last 12 months have you..? *

Had any medical condition, illness or injury that you've received treatment for over a continuous period of 4 weeks or more *

Been referred to or had any investigations in hospital, for example biopsy, scan, ECG *

If you answered, "YES" to any of the questions above, please provide details in the box below including the date you last saw your consultant, if you have a follow up appointment planned, if you have any further tests scheduled or if you have been discharged from treatment:

Pending medical results *

Are you awaiting any results from your doctor or the hospital that you feel we should be informed about *

Please provide details in the box below:

If any medication is currently being taken please provide details:

Please provide details in the box below:

Have any of your natural parents, brothers or sisters, before the age of 65, had any of the following conditions?You answered YES to one or more of the above conditions. Please provide details in the box below:

Any other condition that runs in your family and that you're receiving regular follow up or screening for? *

Are you awaiting any results from your doctor or the hospital that you feel we should be informed about *

Section 7

...AND FINALLY!

We want to provide personalised recommendations tailored to your preferences. To achieve this, please answer a few simple questions below to help us understand your priorities. *

Would you like to replace your income if you were unable to work due to illness or injury? *

I’M INTERESTED UNSURE NOT INTERESTED

Would you like to know the options open to you if you were not able to work due to being diagnosed with a serious or life changing illness? *

I’M INTERESTED UNSURE NOT INTERESTED

Would you like to have access to GP services for you and your family, including prescriptions, second medical opinions, and virtual consultations no matter where you are in the world? *

I’M INTERESTED UNSURE NOT INTERESTED

This questionnaire supports an initial protection review. It is not an insurance application and does not place cover in force. Wilding Mortgages or an insurer may need further information.

Health questionnaire

Questionnaire unavailable

Personal details

Your doctor's details

Work, total cover & travel

Mental Health

Hazardous activities

HEALTH AND LIFESTYLE

Have you ever had any of the following? *

During the last 5 years have you seen a health professional for any of the following? *

During the last 5 years have you seen a health professional for any of the following? *

During the last 12 months have you..? *

Pending medical results *

Any other condition that runs in your family and that you're receiving regular follow up or screening for? *

...AND FINALLY!

Questionnaire received