PROTECTION QUESTIONNAIRE Step 1 of 5 20% Name* First Last Height* Weight* Please confirm your waist or dress size* If you have had any significant weight loss or gain in the last 12 months, please detail Do you smoke tobacco or use e-cigarettes / vaporisers?* Yes No Have your ever smoked tobacco or used e-cigarettes / vaporisers?* Yes No If you answered yes above when did you stop? Average weekly alcohol consumption Monday - Thursday* Average weekly alcohol consumption Friday - Sunday* Have you ever exceeded 30 units per week or been advised to reduce / stop alcohol intake on medical grounds? If YES please detail why, when and if you are undergoing any treatment*Have you ever injected non prescription drugs or used recreational drugs?* Yes No If YES, please detail what and whenHave you ever been declined or deferred from a protection application?* Yes No If YES, please give detailsDo you currently have a protection product similar to that you are applying for?* Yes No If YES, please give details of Sum/s Assured, Type of Cover and Provider/sIf YES, are you applying for: Replacement Cover Additional Cover What percentage of your daily employment involves manual work?* How many business miles do you travel per year?* Have you ever lived / travelled or worked abroad for more than 30 consecutive days?* Yes No Does your work involve heights, working underground, diving or use of dangerous tools or explosives?* Yes No If YES, please detailPlease tick any of the hazardous activities or sports you take part in* Aviation Horse Riding Motorsports Climbing Diving Martial Arts Water or Winter Sports Motorcycle Riding None of the above You may need to complete a hazardous pursuits questionnaire from the protection providerIf you selected any of the activities above, please detail your involvement 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. Family HistoryBefore the age of 65, did any of your parents or siblings suffer or die from any of the following conditions? (If you do not know the medical history of your natural parents or siblings or are adopted, then please answer ‘No’)Cancer?* Yes No Heart disease, stroke, diabetes?* Yes No Multiple sclerosis, Alzheimer's disease?* Yes No Muscular dystrophy, Parkinson’s disease, motor neurone disease, hemochromatosis?* Yes No Huntington’s disease, polycystic kidney disease or polyposis of the colon?* Yes No Any other hereditary disorder?* If YES to any of the above, please give details Doctors DetailsDoctor Name* Surgery Name* Surgery Address* Street Address Address Line 2 City Post Code Telephone* Time with Doctor* DeclarationsDo not sign this declaration unless you are entirely satisfied with it’s content. If you have any questions please consult. I/We agree that this confidential questionnaire and review is a true record of My/Our discussion with the adviser and that this information is true to the best of my/our knowledge. I/We accept that this confidential review relates only to mortgage and protection advice and is not a review for investment advice regulated under the financial services act. I/We confirm that the personal and confidential information provided can be disclosed by the adviser for the purpose of arranging a mortgage and/or protection product on my behalf. I/We have read this completed confidential factfind review form before signing below. Name Date NameThis field is for validation purposes and should be left unchanged.