PROTECTION QUESTIONNAIRE

Do you currently have or have had any of the following?

Have you ever tested positive for HIV, hepatitis B or C or awaiting the results of such test?*

Yes
No

Cancer, tumour, leukaemia, Hodgkin’s disease, lymphoma, brain or spinal tumour?*

Yes
No

Heart disease or disorder, including heart attack, angina, cardiomyopathy, heart valve disorder?*

Yes
No

Stroke, transient attack (TIA), brain haemorrhage, permanent brain damage through accident?*

Yes
No

Multiple sclerosis, Parkinson’s disease, epilepsy, paralysis, Alzheimer's disease, dementia, cerebral palsy?*

Yes
No

Any other disorder of the central nervous system - brain, spinal cord and nerves, not already mentioned?*

Yes
No

Any disease or disorder of the arteries, including disease in the leg or of the aorta?*

Yes
No

Diabetes or sugar in the urine?*

Yes
No

Mental illness that has required hospital treatment or referral to a psychiatrist or other specialist?*

Yes
No

Skin disease such as psoriasis or dermatitis?*

Yes
No

If you answered YES to any of the above, please give details of diagnosis, date of diagnosis, time off work, treatment and if you are fully recovered.

In the last 5 years, have you had any of the following?

Have you currently got or had coronavirus, or have you had to/currently having to isolate due to being in direct contact with someone who has the disease?*

Yes
No

A lump, growth of any kind; or any mole or freckle that has changed size or led to bleeding?*

Yes
No

Any blood circulatory problem, chest paid, irregular heartbeat, raised blood pressure or raised cholesterol?*

Yes
No

Asthma?*

Yes
No

Bronchitis or any other respiratory disorder?*

Yes
No

Numbness, loss of feeling or tingling of the face, or temporary loss of muscle power?*

Yes
No

Seizure, fits, epilepsy, fainting, dizziness or blackouts?*

Yes
No

Disorder of the eyes including blurred or double vision, optic neuritis?*

Yes
No

Disorder of the ears, hearing or balance?*

Yes
No

Arthritis, rheumatoid arthritis, spine, back, neck or joint disorder, including slipped disk and gout?*

Yes
No

Any disorder of the digestive system, liver, stomach, pancreas or bowel, including ulcers, Crohn’s disease?*

Yes
No

A blood disorder or anaemia?*

Yes
No

Thyroid disorder?*

Yes
No

Kidney, bladder, or any other disease of the genitor-urinary system?*

Yes
No

Any sexually transmitted disease or infection?*

Yes
No

Any cervical smear needing treatment, investigation or advice, gynaecological disorder or breast problems?*

Yes
No

Prostate enlargement or abnormal PSA?*

Yes
No

Received any form of medical attention at a hospital?*

Yes
No

Any occurrence of depression, stress, nervous breakdown, anxiety or any other mental health issue?*

Yes
No

Had any surgical operation?*

Yes
No

Undergone or been advised to have any investigation, x-ray, scan or blood test for any other condition?*

Yes
No

Are you awaiting results of any medical investigation?*

Yes
No

Are you currently taking any prescribed drugs?*

Yes
No

Have you been off work for 2 weeks or more for any condition not already mentioned?*

Yes
No

Do you intend to seek advice from a medical practitioner for anything not already mentioned or diagnosed?*

Yes
No

Considering the types of questions above, is there any other medical disclosure you would like to make?*

Yes
No

If you answered YES to any of the above, please give details of diagnosis, date of diagnosis, time off work, treatment and if you are fully recovered.

Step 1 of 5

Do you currently have or have had any of the following?

In the last 5 years, have you had any of the following?

Family History

Doctors Details

Declarations

TERMS & CONDITIONS

Making sure your family is protected

Why do you need it?

What will the State provide?