6. Diabetes, thyroid or other glandular or blood disorders (e.g. anaemia or bleeding disorders, leukaemia, haemophilia)? Yes No
7. Eye, ear, nose or throat disorder (e.g. defective vision, hearing loss, ear discharge, recurrent tonsillitis, hoarseness, retinitis pigmentosa,
8. Nervous or mental complaint (e.g. epilepsy, blackout, paralysis, anxiety state or depression, chronic headaches, ﬁts, fainting, multiple
sclerosis, brain impairment)?
9. Disorder or disease of the skin eruption, (e.g. porphyria, psoriasis, dermatitis, muscles, bones, joints, limbs or spine, e.g. rheumatism,
arthritis, gout, slipped disc or other back condition)?
10. Any tropical disease (e.g. bilharzia, malaria, brucellosis)? Yes No
11 . Cancer, a growth or tumor of any kind? Yes No
12. Any other illness, disorder or operation, disability or accident, (INCLUDING MOTOR VEHICLE ACCIDENTS) which required medical,
radiological, surgical, pathological investigations, or have you ever been hospitalised?
13. Do you or any of your dependants have any physical (including dental), abnormality, deformity, handicap or defect, whether congenital
or as a result of an accident, disease or some other cause? For dental system (poor closure of jaws, implants, orthodontic, periodontic
or maxillofacial surgery).
14. Are you or your dependants currently undergoing or expecting to undergo any medical, dental, or surgical treatment? Yes No
15. Are you or any of your dependants pregnant? If yes, state expected date of delivery. Yes No
If the answer to question 15 is YES, please answer the following questions:
16. Did you or any of your immediate family e.g. mother, dependants, sister experience any complications with previous pregnancies? Yes No
17. Are there any complications or health problems detected in you or your immediate family ‘s current pregnancy or that of the unborn
18. Does any member of your (or your spouse’s) immediate family e.g. parents, brothers or sisters suffer from diabetes, heart disease, high
blood pressure, raised cholesterol, mental disease, porphyria or any other disease?
19. Did you experience any health problems or show signs and symptoms of health problems in the last 3-months before applying for
20. Has your weight or the weight of your spouse/dependant changed more that 5kg in the last 12 months? If so, why? Yes No
21. Are you or your dependants smokers? Yes No
22. Are there any addictions we should be aware of? Yes No
23. Height & weight (Principal member)
Height & weight (Spouse)
Height & weight (child 1)
Height & weight (child 2)
Height & weight (child 3)
Height & weight (child 4)
Height & weight (child 5)
If you have answered ‘yes’ to any of the above questions please provide the full details below:
(Name of Person)
Date and duration of
the illness or condition
Date and nature of
medical or surgical
result of treatment
Name of doctor,
hospital or institution
date and duration of
If more space is needed, please attach list.