Lifestyle and Medical Questionnaire

Please complete this questionnaire accurately. Your answers are vital for your protection coverage.

Municipal Financial Planning together with St. James's Place plc are the data controllers of any personal data you provide to us. For further information on our uses of your personal data, please see our Privacy Policy here

Personal Details

Full Name

Date of Birth

Sex

Marital Status

Email Address

Contact Number

Full Address (including postcode)

Your Measurements

Feet *

Inches *

Stone *

Pounds *

What is your waist size (in inches) or dress size?

What is your smoking status?

Approximately how many units of alcohol do you drink each week?

Protecting What Truly Matters

If you were to die, is it important that your family stays financially secure?

If you got cancer or became critically ill, would it be important to you to stay financially secure and get access to leading treatment?

If you were unable to work due to an accident or illness, would it be important to have your income replaced so you could keep up with everyday expenses and financial commitments?

If you were unable to work because of illness or an accident, how long could you currently manage financially?

Do you currently have a will in place?

Would you also like to speak to us regarding a private medical cover?

Do you require any pensions or investment advice and would you like to be connected with a Financial Advisor?

Lifestyle Questions Continued

Have you been in a road traffic accident or had any driving convictions within the last 5 years? *

Do you ride a motorbike on the road? *

Do you participate in any sports? *

Have you ever been advised by a doctor or health professional to reduce your alcohol consumption? *

Have you ever taken non-prescription or recreational drugs? *

Have you had any unexplained weight loss in the last 6 months? *

Family Medical History

Heart attack, angina or cardiomyopathy? *

Family history

Cancer? *

Family history

Stroke? *

Family history

Diabetes? *

Family history

Multiple Sclerosis? *

Family history

Myotonic or Muscular Dystrophy? *

Family history

Your Medical History

Heart attack, irregular heartbeat, cardiomyopathy, valve disorder or any other heart condition or heart surgery? *

Own history

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

Own history

Epilepsy, multiple sclerosis, muscular dystrophy, cerebral palsy, motor neurone disease, Parkinson's disease, or optic neuritis? *

Own history

A cyst, growth or tumour in either your brain or spine? *

Own history

A stroke, TIA, brain haemorrhage or damage or surgery to your brain? *

Own history

Diagnosed with an eating disorder, bipolar disorder or manic depression, schizophrenia, psychosis, personality disorder or any compulsive disorder? *

Own history

Diagnosed with ME or fibromyalgia? *

Own history

A positive test for HIV, hepatitis B or hepatitis C? *

Own history

Diabetes? *

Own history

Recent Medical History (Last 5 Years)

In the last 5 years, have you been diagnosed or have you seen a doctor, nurse or other health professional for raised blood pressure or raised cholesterol? *

Own history

Any condition affecting the veins, blood or blood vessels? *

Own history

Any condition affecting your kidneys or bladder? *

Own history

Any condition affecting your stomach, oesophagus or bowel? *

Own history

Any condition affecting your gall bladder, liver or pancreas? *

Own history

Any condition affecting your lungs or breathing? *

Own history

Lupus, fibromyalgia or gout? *

Own history

Any abnormal cervical smear, any gynaecological disorder, or any prostate issues? *

Own history

Arthritis, neck, back, spine, joint or muscle trouble? *

Own history

Depression, anxiety, stress or any other mental health condition? *

Own history

What is the name of your condition? *

When did you first get diagnosed? *

When did you last experience symptoms or have any concerns? *

Did you ever have suicidal thoughts or tried to take your own life because of this? *

Have you ever stayed overnight in hospital or seen a psychiatrist because of this? *

Please provide any further details. *

Have you fully recovered from your condition? *

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

Own history

Chest pain, palpitations or irregular heartbeat? *

Own history

Paralysis, numbness, persistent tingling or pins and needles, tremor or facial pain, memory loss, dizziness or balance problems? *

Own history

Had a mole, freckle, investigated or changing colour? *

Own history

Any condition affecting your thyroid? *

Own history

Any condition affecting your eyes or ears? *

Own history – that is not wholly corrected with glasses or contact lenses.

Work-Related Questions

In the last 5 years, have you been off work due to illness or accident? (excluding what you have already told us about) *

Does your occupation involve working offshore in oil, gas, or fishing industries, underground, handling explosives, flying, diving, or are you in the armed forces (including reserve or territorial forces)? *

Does your occupation involve working at heights? *

Does your occupation involve any manual work? *

Does your occupation involve any driving? *

Additional Medical & Travel Questions

Have you ever had surgery outside the UK? *

In the last 5 years, have you attended any doctor, hospital, or clinic for any medical advice, treatment, investigations, or tests for anything else that you haven’t already told us about? *

Are you waiting for the results of any test or investigation? *

In the last 5 years, have you spent more than 3 weeks in a row outside the UK? *

In the next 12 months, do you intend to spend more than 3 weeks in a row outside the UK? *

Have you been registered with a doctor's surgery within the UK in the last 5 years? *

Are you happy for the insurance provider to obtain your GP report if needed? *

If not, your application may not be processed or submitted, as a GP report may be a requirement.

Do you need to see the GP report before it’s sent to the provider? *

Lastly, is there any other medical condition that you have not yet told us about? *

Lifestyle and Medical Questionnaire

Personal Details

Financial Details

Your Measurements

Protecting What Truly Matters

Lifestyle Questions Continued

Family Medical History

Your Medical History

Recent Medical History (Last 5 Years)

Work-Related Questions

Additional Medical & Travel Questions

Form Submitted Successfully!