New form Personal InformationToday's Date MM slash DD slash YYYY Your Name(Required) First Last Date of Birth DD slash MM slash YYYY HeightWeightLifestyle QuestionsWhat is your Smoker/Vape/Nicotine Replacement status? Never Stopped 1 year+ Within 12 months but not regularly Other nicotine replacement products in the last 12 months Family Medical HistoryBefore age 65, have your birth parents or blood siblings experienced or died from any of the following? Heart attack, angina, stroke Yes No Don't know Cardiomyopathy Yes No Don't know Diabetes Yes No Don't know Bowel cancer or bowel polyps Yes No Don't know Any other cancer Yes No Don't know Muscular dystrophy, Huntington’s, Motor Neurone Yes No Don't know MS, Parkinson’s, Alzheimer’s Yes No Don't know Polycystic kidney Yes No Don't know Current Health and ActivitiesAre you currently: Off work or on reduced hours due to sickness/injury? Yes No Riding a motorcycle/moped on the road? Yes No Recent Symptoms (Last 3 Months)Have you experienced any of the following? (F) Abnormal changes to either breast (lumps, growths, hardening, nipple abnormalities) Yes No More info(M) Abnormal changes to testicle (lumps, growths, hardening) Yes No More infoBleeding from bowel or change in bowel habit Yes No More infoCough lasting more than 3 weeks Yes No More infoA fit or seizure Yes No More infoA mole or skin blemish which has changed in appearance Yes No More infoPast Health HistoryIn the last 2 years: Have you lived or worked outside the UK/EU or plan to in the next year? (Ignore business trips of less than a week or holidays of less than 30-days) Yes No More infoIn the last 3 years: Taken or been prescribed treatment for 4+ weeks Yes No More infoIn the last 3 years: Attended regular follow-ups or reviews with a GP, hospital, or clinic Yes No More infoIn the last 3 years: Been advised to see a specialist or undergo tests, scans, or counseling Yes No More infoIn the last 5 years: Mental health issues (e.g., depression, anxiety, stress, etc.) Yes No More infoIn the last 5 years: Raised blood pressure, cholesterol, or chest pain Yes No More infoIn the last 5 years: Diabetes, borderline Diabetes, pre-Diabetes, raised blood sugar or sugar in the urine Yes No More infoIn the last 5 years: Anaemia, blood clot or anything else affecting your blood Yes No More infoIn the last 5 years: A growth, lump or cyst Yes No More infoIn the last 5 years: Asthma, sleep apnoea or anything else affecting your lungs or breathing Yes No More infoIn the last 5 years: Crohn’s, colitis, IBS or anything else affecting your stomach or digestive system Yes No More infoIn the last 5 years: Kidney stones, urinary infection or anything else affecting your kidney, bladder or urine Yes No More infoIn the last 5 years: (F) Abnormal cervical smear or other gynaecological disorder requiring regular follow up Yes No More infoIn the last 5 years: Anything affecting liver or pancreas Yes No More infoIn the last 5 years: Back pain, sciatica, whiplash or anything affecting your back or neck Yes No More infoIn the last 5 years: Arthritis, gout or anything else affecting your bones, joints, ligaments, tendons or muscles Yes No More infoIn the last 5 years: Numbness, pins and needles, muscle weakness, tremor or difficulty with coordination Yes No More infoIn the last 5 years: Tinnitus, labyrinthitis or anything else affecting your ears, hearing or balance Yes No More infoIn the last 5 years: Impaired, blurred or double vision, optic neuritis or anything else affecting your eyes Yes No More infoIn the last 5 years: Chronic fatigue syndrome, ME, fibromyalgia, or persistent tiredness Yes No More infoIn the last 5 years: Convicted of careless or dangerous driving (Ignore speeding offences, spent convictions or anything not resulting in a ban) Yes No Other Lifestyle and ActivitiesRecreational Drug Use: Have you used recreational drugs in the last 10 years? Yes No Have you ever had: Eating disorder, bipolar, manic depression, schizophrenia, psychosis, personality disorder. Yes No More infoHave you ever had: Tried to take your own life Yes No Have you ever had: Had thoughts about taking your own life or none Yes No Have you ever had: Intentionally harmed yourself Yes No Have you ever had: Had thoughts about harming yourself Yes No Have you ever had: Cancer, cancer in situ, leukaemia, Hodgkins Disease or other tumour Yes No More infoHave you ever had: Heart attack, irregular heartbeat, cardiomyopathy, valve disorder or other heart disease or disorder Yes No More infoHave you ever had: Stroke, TIA, brain haemorrhage, or damage or surgery to brain Yes No More infoHave you ever had: MS, epilepsy, Parkinsons or any other disorder of the brain or nervous system Yes No More infoHave you ever had: Positive HIV Test Yes No More infoHave you ever had: Hepatitis B or C Yes No More infoHave you ever had: A test for HIV, Hep B/C or awaiting results of a test Yes No More infoHave you ever had: Been treated in hospital for coronavirus Yes No More infoHave you ever had: Experience Coronavirus symptoms for 12wks or more (Long Covid) Yes No More infoHave you ever had: Been advised by a medical professional to cut down or stop drinking alcohol Yes No Have you ever had: Attended or been referred to alcohol or drugs specialist support such as Alcoholics or Narcotics Anonymous Yes No Have you ever had: Banned from driving Yes No Alcohol ConsumptionWhat is your average alcohol intake per week (over the last 3 months)? Pints of beer/lager/ciderGlasses of wine (175ml)Measures of spiritsOther alcoholic drinksHobbies and ActivitiesDo you participate in any of the following? (Not fare paying passenger/cabin crew, track/experience days, one off jumps/scuba dives) Armed forces reserves Scuba diving Private flying, gliding, parachuting Motor car or motorcycle sport Mountaineering or rock climbing Saling at sea or powerboat racing Martial arts or combat sport Off piste snow sports Professional or semi-professional sport Work DetailsWhat percentage of your average working day is spent doing the following: Percentage of heavy manual work (eg carrying items 10kg+, working with heavy machinery or digging)Percentage of light manual workSupervisoryAdministrativeAnnual business mileageDoes your job involve: Working at heights of more than 12m/40ft Flying other than as a fare paying passenger on commercial airlines General labouring or using heavy machinery Diving Fishing or merchant marine Oil or natural gas production Armed forces Armed forces reserves Mining, tunnelling or quarrying DeclarationPlease confirm that you agree to us using your lifestyle and health information to continue the process and get your quotes from insurers via UnderwriteMe. I agree