Medical data capture form

Transcription

1 Medical data capture form 10 most commonly disclosed medical conditions Guidance This form contains the supplementary questions that our online application system will ask for the 10 most common medical disclosures. Please indicate which condition(s) affect you and answer the questions that apply. Your Adviser will then transfer this information onto our online application system. asthma backache depression diabetes growths, cysts and lumps heartburn heart disease high cholesterol hypertension musculo-skeletal injuries

2 Hypertension (High blood pressure, raised blood pressure, blood pressure, B.P) Q1. Do you also have diabetes? Q2. Do you also have raised cholesterol? If applicant is female and aged 50 or under please answer questions 3 and 4. If not, skip to question 5. Q3. Are you currently pregnant? Q4. Was your raised blood pressure diagnosed during pregnancy? If yes, have you had your blood pressure checked since the delivery date? Q5. Have you been diagnosed with any of the following? (Please tick all that apply) Heart defect or heart disorder Kidney problem or urine abnormalities ne of the above Q6. Are you currently on treatment for raised blood pressure? Never been on treatment current treatment and discharged from follow-up current treatment but currently under follow-up Currently on treatment Stopped treatment without medical approval Q7. When was your blood pressure last reviewed?

3 Q8. At your last review for raised blood pressure were you advised of any of the following? (Please tick all that apply) Advised to start or increase treatment Treatment remained the same or has been decreased Treatment was stopped Advised to attend a review in less than 6 months Advised to attend a review in 6 months or later Discharged from follow up Referred to a specialist Q9. Do you know what your last blood pressure reading was? If yes, please include first part of reading (systolic) and second part of reading (diastolic) If your smoker status is smoker Q10. How many cigarettes do you smoke per day?

4 Diabetes mellitus (Type 1 or 2 diabetes, insulin or non insulin dependent diabetes) Q1. Do you also have raised blood pressure? Q2. Do you also have raised cholesterol? Q3. What age were you when this condition was diagnosed? Q4. Has your treatment changed or increased or have you been advised to have more frequent reviews in the last year? Q5. Have you been diagnosed with diabetes within the last 6 months? Q6. Was your last diabetes review within the last 1 year? Q7. What exactly was your last HbA1c result? Q8. Have you ever been diagnosed with any of the following? (Please tick all that apply) Angina, a heart attack or Ischaemic heart disease A stroke or a TIA (transient ischaemic attack) Chronic Kidney disease (CKD) Peripheral vascular disease ne of these Q9. Do you consume more than 40 units of alcohol per week, or have you done so at any time in the last 5 years? Q10. In the last 5 years, have you had any admission to hospital for a very low or very high amount of sugar in your blood (hypoglycaemia or hyperglycaemia)? Q11. Have you had any protein in your urine? t known

5 Q12. Have you ever been diagnosed with any of these diabetic eye problems? (Please tick all that apply) Background retinopathy Maculopathy (blurred vision) Proliferative retinopathy (loss of areas of sight) Detached retina or haemorrhage (loss of vision) I have a diabetic eye problem but the type is not known diabetic eye problems Q13. Do you have or have you had a foot ulcer lasting for longer than 6 months, gangrene or an amputation? Q14. Have you ever been diagnosed with cardiac neuropathy? Q15. Have you ever had numbness or tingling in your legs, feet or hands; or been diagnosed with peripheral neuropathy? t known Q16. Are you currently on treatment for raised blood pressure? Q17. Are you currently on treatment for raised cholesterol?

6 Asthma (Mild asthma, allergic asthma, seasonal asthma) Q1. Were the first symptoms of this condition more than 2 years ago? Q2. Have you been admitted to hospital within the last 2 years with this condition? Q3. Have you been prescribed oral steroids for more than 7 days in the last 2 years? Q4. Have you had breathlessness, wheezing or any other respiratory symptoms which have caused the following in the last 2 years? (Please select all that apply) You have had to change your job, your occupational duties, or give up work You have had to take more than 2 weeks off work You have been unable to walk for 200m without breathing difficulty or chest pain over a period of more than 1 week Breathlessness or wheezing even when resting (other than for a short period lasting less than 1 week) You have needed to use oxygen therapy ne of the above Q5. How many asthma attacks have you had in the last year? Q6. When did you last have symptoms of this condition? Q7. Is your asthma made worse by your occupation? Q8. Have you had an episode of status asthmaticus in the last 12 months? If your smoker status is smoker Q9. How many cigarettes do you smoke per day?

7 Depression (Stress, anxiety, panic attacks, post-traumatic stress, work-related stress) Q1. When was this condition first diagnosed? Q2. When did you last have symptoms of this condition? Q3. Which of the following have you visited regarding this condition in the last five years? (Please tick all that apply) GP Nurse / CBT Psychiatrist Inpatient treatment at hospital ne of the these Q4. How many days have you taken off work because of this condition in the last 2 years? Q5. Are you currently on treatment for this condition? If currently on treatment please answer questions 6 and 7, otherwise please skip to question 8 Q6. What type of treatment are you currently taking? (Please tick all that apply) Antipsychotic medication e.g. Chloropromazine Antimanic medication e.g. Lithium Antidepressant medication e.g. Fluoxetine, Citalopram Herbal medication e.g. St John s Wort Other medication

8 Q7. Has there been any change to your treatment in the last year? change - same type and amount of medication Amount of medication has increased Amount of medication has decreased on medical advice Amount of medication has decreased for other reasons Type of medication has changed If not currently on treatment Q8. Have you ever taken medication for this condition? Q9. Have you ever been advised to take medication for this condition? Q10. What type of treatment were you advised to take? (Please tick all that apply) Antipsychotic medication e.g. Chloropromazine Antimanic medication e.g. Lithium Antidepressant medication e.g. Fluoxetine, Citalopram Herbal medication e.g. St John s Wort Other medication Q11. Was your condition related to a specific event? Q12. Have you ever required inpatient treatment? Q13. Have you ever taken an overdose of drugs, attempted suicide or had suicidal feelings?

9 If the answer to question 13 is yes, please answer the following Q14. How many times have you attempted suicide or had suicidal feelings? Q15. Q16. Please give the approximate date of your overdose, suicide attempt or suicidal feelings (if you have had more than one please give the latest date)? Please provide any further information on your depression and suicide attempt or feelings

10 High cholesterol (Raised cholesterol, raised lipids) Q1. Do you also have diabetes? Q2. Do you also have raised blood pressure? Q3. Have you been diagnosed with any of the following? (Please tick all that apply) Heart defect or heart disorder Kidney problem or urine abnormalities Familial hypercholesterolaemia ne of the above Q4. Are you currently on treatment for raised cholesterol? Never been on treatment current treatment and discharged from follow-up current treatment but currently under follow-up Currently on treatment or diet controlled Stopped treatment without medical approval Q5. At your last review for raised cholesterol, were you advised of any of the following? (Please tick all that apply) Advised to start or increase treatment Treatment remained the same or has been decreased Treatment was stopped Advised to attend a review within 6 months Advised to attend a review in 6 months or later Discharged from follow-up Referred to a specialist

11 Q6. When was cholesterol last reviewed? Q7. Do you know your last cholesterol reading? Only answer the next question if your last cholesterol reading was within the last 545 days (18 months ago) Q8. Please tell us your last cholesterol reading (if known) If your smoker status is smoker Q9. How many cigarettes do you smoke per day?

12 Backache (Back pain, sciatica, whiplash, slipped disc, back injury, bad back) Q1. Are you awaiting an operation for this condition? Q2. Have you had surgery for this condition? Q3. Which of the following best describes the severity of your condition? symptoms in the last two years Minor symptoms (eg early morning stiffness), no significant effect on lifestyle or mobility Restriction in previous activities or pastimes Persistent pain, limited range of activities, use of aids to assist mobility Bedridden or confined to a wheelchair with little or no self care Q4. When did you last have symptoms of this condition? Q5. Where did you suffer pain? (Please tick all that apply) Neck Upper back Central back Lower back General back pain Q6. How many days off work have you had with this condition? Q7. On how many separate occasions have you experienced symptoms of this condition?

13 Heartburn (Dyspepsia, acid reflux, indigestion, stomach acid, gastric reflux) Q1. Have you been told that your symptoms are complicated by or related to another condition?: Ulcer Barret s Oesophagus Oesophageal stricture or obstruction Hiatus hernia Another condition related conditions If the answer to question 1 is another condition, please tell us the name of the condition: Q2. Have you ever been referred to a specialist or required hospital investigations because of this condition? If the answer to question 2 is yes, please answer question 3: Q3. What were the results of your investigations? All normal They were not normal Still awaiting investigations / results t sure Q4. Have you sought medical advice from your GP for this condition? If answer to question 4 is no, please answer question 5. If answer to question 4 is yes, please answer question 6.

14 Q5. What treatment were you recommended following your review? treatment and not under any planned follow-ups or investigations Given regular prescription medication (e.g. omeprazole, lansoprazole, ranitidine or cimetidine) Just advised to cut down on triggers such as coffee, smoking or fatty foods Have been advised to have further investigation or follow-up Advised over the counter medication only when needed Q6. Have the symptoms started or increased in severity or frequency in the past 6 months?

15 Heart disease (Ischaemic heart disease, angina, heart attack, coronary heart disease) Q1. Were you first diagnosed with this condition within the last 6 months? If the answer to question 1 is yes, then there s no need to answer the remaining questions Q2. At what age did you first experience symptoms for your condition? Q3. Have you ever been diagnosed with any of the following? Atrial flutter or Atrial fibrillation Diabetes A Stroke, cerebral haemorrhage or TIA (transient ischaemic attack) Peripheral vascular disease or intermittent claudication ne of the above Q4. Have you had a heart attack? If the answer to question 4 is yes, please answer questions 5-6. If no, skip to question 7 Q5. How many times have you suffered from a heart attack? Q6. When was your last heart attack? Q7. Have you had an operation for this condition? If the answer to question 7 is yes, please answer questions If no, skip to question 14

16 Q8. On what date was your operation carried out? Q9. Have you suffered from chest pains or shortness of breath in the last three months? Q10. Are you on treatment for raised blood pressure? Q11. Are you on treatment for raised cholesterol? Q12. Have you suffered with palpitations or an irregular heartbeat in the last three months? Q13. Please advise the number of vessels that were treated Q14. In the last 12 months have you had? Chest pain, tiredness or palpitations when resting Chest pain, tiredness or palpitations with normal activity. rmal activity is defined as walking/climbing the stairs at a steady pace Chest pain, tiredness or palpitations with physical activity such as walking uphill or when walking/climbing the stairs at a rapid pace Occasional chest pain with no limitations on normal activity such as walking uphill or when walking/climbing the stairs at a rapid pace symptoms within the last 12 months Q15. When did you last see your GP or a specialist for this condition (including routine reviews)? Q16. Are you awaiting specialist investigations or an operation for this condition? Q17. When did you last have a stress ECG or Echocardiography? Within the last year 1 to 3 years ago 3 to 5 years ago Over 5 years ago

17 Musculo-skeletal injuries (Shoulder injury or pain, broken ankle, arm wrist or leg, dislocated or frozen shoulder, fractured wrist, arm or leg) Q1. Please choose the site of the musculo-skeletal injury from the following: Skull Spine Hands (inc. fingers), toes, jaw, collar bone, cartilages and ligaments Knees, shoulder, feet, arms, wrist, elbows, hips and femur, leg (inc. ankle) Pelvis Q2. What was the cause of the injury? Accident or injury Medical condition If the answer to question 2 is medical condition please tell us the name of the underlying condition: Q3. Are you currently awaiting an operation for this condition? Q4. How many days have you taken off work because of this condition in the last 12 months? Q5. Have you fully recovered from this condition? If you have not fully recovered from this condition, please answer the following questions: Q6. Please describe your symptoms including exactly which part/s of your body is affected by the problem

18 Q7. What treatment do you take or undergo? (Please include prescription medication and physical treatment for example chiropractic or physiotherapy) Q8. How much time have you had off work with this?

19 Growths, cysts, lumps etc (Cyst, lump, mole, polyp, fatty lump, growth) Q1. Are you waiting for any investigations, or the results of investigations, for this condition? Q2. Was the growth located on the skin? If the growth was not located on the skin, please skip to question 10 If the growth was located on the skin, please continue with question 3 Q3. Has the growth been completely and totally removed? It has been completely and totally removed It disappeared without surgery It has not been completely and totally removed Q4. Who have you sought medical advice from for this condition? GP only Both my GP and a dermatologist A dermatologist only I have not sought medical advice You only need to answer question 5 if you have not sought medical advice Q5. Are you intending to seek the advice of a medical practitioner for this condition? If you answered yes to question 5, there are no more questions Q6. When was the growth first discovered? (Please give the approximate date) Q7. Since you sought medical attention for this condition, has the growth become painful, bled, increased in size or changed colour?

20 If you answered yes to question 7, there are no more questions Q8. Are you under regular follow up or have you been advised to re-attend your GP or a specialist for this or any other growth, lump, cyst or mole? Q9. Has the growth ever been described as malignant or cancerous? If no, what was the growth diagnosed as? Birthmark or freckle Mole, cyst or skin tag Rodent ulcer or Basal cell carcinoma Nasal polyp Sebaceous/Sebhorrhoeic keratosis or Sebaceous/Sebhorrhoeic wart Ganglion or fibroma t sure ne of the above Only answer question 10 if the growth was not located on the skin Q10. Where was the site of the growth? Breast Kidney Spine Ovary Testicular Prostate Other

21 Only answer questions 11 and 12 if the site of the growth was testicular Q11. Has the growth ever been described as malignant or cancerous? Q12. Was your testicular lump diagnosed as a variocele or hydrocele? You only need to answer question 13 if you are not sure of the diagnosis, if the answer to question 10 was other or you have not sought any medical advice. Q13. Please describe this condition in your own words including: site of growth, name of the growth (if known), details of any treatment, follow ups or investigations Q14. When your tumour was first found, had it spread to any other part of your body or lymph nodes? Q15. Approximately when did you last have chemotherapy, radiotherapy or surgery for this condition? AIG Life Limited. Telephone Registered in England and Wales. Number Registered address: The AIG Building, 58 Fenchurch Street, London EC3M 4AB. AIG Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. The registration number is EDCO