PRIVATE & CONFIDENTIAL
STANDARD MEDICAL EXAMINATION FORM
Policy No: Insurance Co:
Client Name: Date of Birth:
Photo ID Checked Document Type: Document Number:
Yes No
………………………………. ……………………………….
Instructions for Completion:
Please ensure that all questions are answered. In the event of any ‘Yes’ responses we require
full and comprehensive details in the Supplementary Information sheet on page 5 to include:
(1) Name and details of the condition (2) Details of treatment (3) Related historical & future
medical appointments (4) Attending medical examiners (5) Outcomes and medication (6)
Follow up’s (7) Recommendations (8) All applicable dates and any further comments.
MEDICAL HISTORY
YES NO
1 Are you at present under medical care or receiving treatment?
2 Are you awaiting investigations, the results of investigations or aware of any symptoms
you haven’t yet seen a medical practitioner about?
3 Have you consulted your doctor (GP) in the last 2 years?
4 Have you been referred for any consultant's opinion in the last 5 years?
5 Have you ever had any chest x–rays, ECG, scans, endoscopy, colonoscopy, blood or
urine tests or any other screening procedure or investigation? If so give reasons, dates
and results.
6 Have you ever had any surgery or hospitalisations?
7 Have you had any time off work due to accident or illness during the last 2 years?
8 Are you currently taking any medication? If yes, please complete the table below:
Which medication are you What is the dosage? What are you taking How long have you
taking? the medication for? been taking it?
9 Have you ever taken drugs other than those prescribed by any doctor? Y N
Have you ever suffered from any of the following illnesses or had any associated
symptoms - In the event of any ‘Yes’ responses we require full and comprehensive YES NO
details in the Supplementary Information sheet on page 5:
10 Any disease or disorder of the Heart or Circulatory system including heart attack,
angina, chest pains, shortness of breath, palpitations, heart murmur or other disorders
of the heart, stroke, TIA or other circulatory conditions?
11 Any history of, or treatment for, high blood pressure or raised cholesterol?
12 Any disease or disorder of the Respiratory system including asthma, bronchitis,
pneumonia, tuberculosis, emphysema, pleurisy, whooping cough, coughing of blood or
other lung disorder?
13 Any disease or disorder of the Digestive system such as abdominal pain, persistent or
recurrent indigestion or peptic ulcer, jaundice, hepatitis or other liver disorder, gall
stones, hiatus hernia, persistent diarrhoea, intestinal complaint, unexplained weight
loss, colitis, rectal bleeding?
14 Any mental health issues, including anxiety, stress, tension or depression, psychosis,
schizophrenia, or any history of self-harm or suicide attempts?
15 Any nervous disorder such as: severe headaches, migraine, convulsions, fits, epilepsy,
double vision, fainting, giddiness, numbness or paralysis, Motor Neurone Disease,
Parkinson's Disease or multiple sclerosis?
16 Any eye or ear disorders?
17 Any diabetes, thyroid disorder or any other glandular disorder?
18 Any skin disorders such as: eczema, psoriasis, moles, lesions?
19 Any rheumatoid or osteoarthritis, back pain (such as sciatica, prolapsed disc), gout or
any other disorder of the joints or muscles?
20 Any disease or disorder of the Kidneys, bladder, prostate, genital organs, gynaecological
or obstetric problems (including abnormal smears)? Or other genitourinary disease
including any presence of blood, glucose or protein in the urine?
21 Any type of blood disorder (such as anaemia or haemophilia)?
22 Any blood transfusions or have you ever received blood products or surgery outside of
the UK or Ireland?
23 Any history of growths, lumps, tumours, cancers or cysts?
24 Have you ever tested positive for HIV / AIDS, Hepatitis B or C, or are you awaiting the
results of such a test?
(Note: In the event of a negative result, the fact of having an HIV test will not have any
effect on your acceptance terms of insurance)
25 Have you ever tested positive for any other sexually transmitted disease, or are you
awaiting the results of such a test?
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Policy number:___________________ V005.1.05122017
LIFESTYLE SECTION
YES NO
26 A Do you smoke?
26 B If yes, how much on average do you smoke Cigarettes Cigars Tobacco (grams)
daily?
27 Have you ever smoked in the past?
28 If you are a former smoker, when did you stop? M M Y Y
29 Did you stop smoking on medical advice?
30 Have you used nicotine replacement products such as nicotine patches, gum or
electronic cigarettes in the last 12 months?
*Please note all Smoker Questions must be answered even if applicant has never smoked*
31 Do you drink alcohol? – If yes please note weekly units below
32 If yes, note weekly Beer Wine Spirits Other alcohol
consumption of alcohol (units)
Beer: Pint of Beer: Pint of Wine: Standard Wine: Large Spirits: Standard
standard = 2 units premium = 3 units (175ml) = 2 units (250ml) = 3 units (25ml) = 1 unit
33 If a total abstainer, how long have you been so?
Y Y
34 Have you ever been advised to reduce the amount you drink, or have you ever
received alcohol related counselling?
35 Has your weight significantly changed in the last 12 months? If yes please state the
amount of loss or gain and the reason for the change, if known.
36 Do you exercise regularly?
37 If yes, what type of exercise and how often?
FAMILY HISTORY YES NO
38 Have your natural parents, brothers or sisters ever suffered from heart disease,
hypertension, stroke, diabetes, raised cholesterol, cancer, kidney disease, multiple
sclerosis and Huntingdon's disease or any other hereditary disorder?
If yes, please complete the table below:
Family Member Age (if living) Diagnosis Age at Diagnosis Age at Death and
Cause
Father
Mother
Brother (s)
Sister (s)
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Policy number:___________________ V005.1.05122017
PHYSICAL EXAMINATION
MUSCULO SKELETAL
YES NO
39 Are there any problems with spinal movements, such as pain or restriction, and are there
any deformities or swelling of the joints?
BASIC MEASUREMENTS
40: Height (without 41: Weight (without 42: Abdominal girth at 43: Hips (at broadest)
shoes) shoes) umbilicus
CM KG CM CM
44 Please record the blood pressure in the table below:
If either the Systolic or Diastolic reading is above 140/90 (5th phase) or if the pulse rate is abnormal
then take two further readings at 5 minute intervals
1st Reading *2nd Reading *3rd Reading
Systolic
Diastolic (5th phase)
Pulse
45 Please record the character of Pulse in the table below:
Please tick the relevant box Regular Irregular
Strong
Weak
46 URINALYSIS SECTION - Please obtain a sample for urinalysis and record the results in the table:
NAD Trace + ++ +++
Protein
Blood
Sugar
If the urine is positive (trace or above) for Protein or Blood (except for women who are menstruating)
then please send the sample to the laboratory for an MSU.
47 Do you have any reason to suspect the sample provided may not belong to the Y N
applicant? If YES, please give details:
48 Is the sample being sent to the laboratory? Y N
49 If the urine was positive, and no sample sent, please indicate why (e.g. Menstruating).
INSTANT COTININE TEST
50 If a Cotinine test was requested, *Positive (1 line) Negative (2 lines)
please record the result here:
51 *If the Cotinine test is positive which is indicated by only 1 line being present please discuss this with
the applicant and note the reason stated:
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Policy number:___________________ V005.1.05122017
Declaration: I declare that I am the person referred to in the information contained in this report and that to the
best of my knowledge and belief the information I have given is true and complete. I understand that the information
given will help determine the terms of which any cover is provided by the Insurance Company. I understand that this
statement and the results of the examination and any tests will be forwarded to a Medical Officer of the Insurance
Company. I hereby consent to the Insurance Company releasing a copy of this report and any test results to any
Doctor who, at any time, has attended me. I agree that a copy of this consent will have the validity of the original.
Applicant Name: Examiner Name:
Applicant Signature: Examiner Signature:
Date: Date:
DD MM YY DD MM YY
EXAMINER COMMENTS - Is there anything which in your opinion calls for further clarification, or have you
advised the applicant to see their GP for any reason?
Nurse Checklist
a) Have you checked that every question has been fully answered and added
supplementary responses in the event of any ‘Yes’ responses?
b) If any lab tests were requested have they been taken and sent to the lab? - If you
were unable to take samples for any reason please state the reason here:
c) Has the report been signed by both parties?
Question
No.
Supplementary Information sheet
In the event of any ‘Yes’ responses we require full and comprehensive details here to include:
(1) Name and details of the condition (2) Details of treatment (3) Related historical & future
medical appointments (4) Attending medical examiners (5) Outcomes and medication (6)
Follow up’s (7) Recommendations (8) All applicable dates and any further comments.
Please scan this form and email to: [email protected]
Page 5 of 5
Policy number:___________________ V005.1.05122017
