Question	Possible Answers	Client Answered
Title	Single Selection: > Mr > Miss > Mrs > Ms > Dr > Professor > Reverend > Other	{field:title_1676827799670}
Other Title	Free text field	{field:other_title_1681722294269}
Your Full Name	Free text field	{field:your_full_name_1676827766860}
Your Email	Free text field	{field:your_email_1676827493426}
Your Telephone Number	Free text field	{field:your_telephone_number_1686661872234}
Date of Birth	Free text field	{field:date_of_birth_1676827929105}
Gender at Birth	Single Selection: > Male > Female	{field:gender_at_birth_1678895585956}
Please select below the name of the Advisor you are dealing with	Single Selection	{field:default_form_advisors}
I agree to my lifestyle and health information being used to continue the process and obtain indicative terms from insurers. I also agree to Health Hub handling my data in line with Health Hub's Privacy Policy.		{field:i_agree_to_my_lifestyle_and_health_information_being_used_to_continue_the_process_and_obtain_indicative_terms_from_insurers_i_also_agree_to_health_hub_handling_my_data_in_line_with_health_hub_s_less_than_a_href_privacy-policy_target_blank_title_opens_in_a_new_tab_greater_than_privacy_policy_less_than_a_greater_than_1685117535236}
I am currently registered, and have been registered with a UK GP, for a minimum of two years.		{field:i_am_currently_registered_and_have_been_registered_with_a_uk_gp_for_a_minimum_of_two_years_1726675271475}
Your full address including postcode	Free text field	{field:your_full_address_including_postcode_1676829391709}
Employment Status	Single Selection: > Employed Full Time > Employed Part Time > Self Employed > Company Director > Retired > Unemployed due to medical reasons > Unemployed / House Person	{field:employment_status_1676829424932}
Marital Status	Single Selection: > Single > Married > Cohabiting > Prefer not to say	{field:marital_status_1725641265331}
Please choose the best description of your smoking status	Single Selection: > I've never smoked > Stopped vaping within the last 12 months > Stopped smoking within the last 12 months > Stopped smoking between 1 and 5 years ago > Stopped smoking over 5 years ago > I currently smoke or vape > I've vaped or used e-cigarettes in the last year > I've used other nicotine replacement products in the last year	{field:please_choose_the_best_description_of_your_smoking_status_1685117553496}
When did you last smoke?	Free text field	{field:when_did_you_last_smoke_1676828304230}
How many did/do you smoke per day?	Free text field	{field:how_many_did_do_you_smoke_per_day_1677841817560}
What is your job?	Free text field	{field:what_is_your_job_1676829629771}
What is your annual taxable income?	Free text field	{field:what_is_your_annual_income_1677841957198}
What is your annual business mileage?	Free text field	{field:what_is_your_annual_business_mileage_1685117576791}
If you have any financial dependants, please list their ages	Free text field	{field:if_you_have_any_financial_dependants_please_list_their_ages_1685117621560}
What percentage of your duties are manual, supervisory or administrative?	Administrative/Clerical	{field:administrative_clerical_1678897132369}
	Light Manual	{field:light_manual_1678897142794}
	Heavy Manual	{field:heavy_manual_1678897150962}
	Supervisory	{field:supervisory_1678897164464}
Does your job involve any of the following duties or working environments?	Checkboxes [ ] Working outside at heights above 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 [ ] Working with explosives [ ] Motor car or motorcycle driving/riding [ ] Full time barman, barmaid or landlord in public house [ ] None of the above	{field:does_your_job_involve_any_of_the_following_duties_or_working_environments_1676829760945:label}
Are you currently off work, or working reduced hours?	Single Selection: > I'm currently off work > I'm working reduced hours > I've altered my duties due to sickness or injury > None of these	{field:are_you_currently_off_work_or_working_reduced_hours_1684404584720}
What sick pay do you receive from your employer?	Free text field	{field:what_sick_pay_do_you_receive_from_your_employer_1678897436544}
Please detail any existing life/illness insurance cover you currently have	Free text field	{field:please_detail_any_existing_life_illness_insurance_cover_you_currently_have_1678897562599}
Do you have a current and up-to-date will?	Single Selection: > Yes > No	{field:do_you_have_a_current_and_up-to-date_will_1689697219751}
Would you look at making a will?	Single Selection: > Yes > No	{field:would_you_look_at_making_a_will_1689697257439}
Life Insurance in Trust? Please enter names and percentages.	Free text field	{field:life_insurance_in_trust_1710850093877}
How tall are you? Enter measurements in...	Single Selection: > Imperial > Metric	{field:how_tall_are_you_enter_measurements_in_1685533962384}
	Height: (Feet/Inches)	{field:height_feet_inches_1685534002871}
	Height: (Metres/Centimeters)	{field:height_metres_centimeters_1685534016871}
How much do you weigh? Enter measurements in...	Single Selection: > Imperial > Metric	{field:how_much_do_you_weigh_enter_measurements_in_1685534050175}
	Weight: (Stone/lb)	{field:weight_stone_lb_1685534087832}
	Weight: (Kilograms)	{field:weight_kilograms_1685534098902}
What is your UK Dress Size or Waistline (Inch)	Free text field	{field:what_is_your_uk_dress_size_or_waistline_inch_1676829606803}
Have your birth parents, brothers, or sisters had any of these health conditions before they were 65?	Checkboxes [ ] Heart attack, Angina, Stroke [ ] Cardiomyopathy [ ] Diabetes [ ] Bowel cancer or bowel polyps [ ] Any other cancer [ ] Muscular dystrophy, Huntington's disease or motor neurone disease [ ] Multiple sclerosis, Parkinson's disease or Alzheimer's disease [ ] Polycystic kidney disease [ ] Polyposis coli [ ] Any other medical condition that runs within the family that you have been tested or advised to monitor [ ] I don't know / No	{field:have_your_birth_parents_brothers_or_sisters_had_any_of_these_health_conditions_before_they_were_65_1684404633086:label}
If you have said yes to the above please provide further information.	Free text field	{field:if_you_have_said_yes_to_the_above_please_provide_further_information_1676886327365}
What type of diabetes did your family member have?	Checkboxes [ ] Type 1 (treated with insulin) [ ] Type 2 (usually treated with tablets or diet) [ ] Gestational Diabetes [ ] Another type of diabetes [ ] Don't Know	{field:family-health-diabetes-type}
Have you had any tests or investigations for this condition indicated in your family history?	Checkboxes [ ] Yes, and the results were normal [ ] Yes, and the results were not normal [ ] Yes, and I'm waiting for the results [ ] No [ ] Don't Know	{field:family-health-tested-for-condition}
In the last 5 years have you had any of these mental health conditions?	Checkboxes [ ] Depression [ ] Anxiety [ ] Stress [ ] Any other mental health issue [ ] None of these	{field:in_the_last_less_than_em_greater_than_5_years_less_than_em_greater_than_have_you_had_any_of_these_mental_health_conditions_1684404659040}
Have you ever had any of these mental health conditions?	Checkboxes [ ] Eating disorder [ ] Bipolar disorder [ ] Manic depression [ ] Schizophrenia [ ] Psychosis [ ] None of these	{field:have_you_less_than_em_greater_than_ever_less_than_em_greater_than_had_any_of_these_mental_health_conditions_1684404691271}
Have you ever tried to take your own life, or had thoughts about taking your own life?	Single Selection: > Tried to take your own life? > Had thoughts about taking your own life? > Neither of these	{field:have_you_less_than_em_greater_than_ever_less_than_em_greater_than_tried_to_take_your_own_life_or_had_thoughts_about_taking_your_own_life_1680010502343}
Have you ever intentionally harmed yourself, or had thoughts about harming yourself?	Single Selection: > Intentionally harmed yourself > Had thoughts about harming yourself > Neither of these	{field:have_you_less_than_em_greater_than_ever_less_than_em_greater_than_intentionally_harmed_yourself_or_had_thoughts_about_harming_yourself_1680010523643}
Please detail dates you were diagnosed/discharged, and any treatments you received, or still receive.	Free text field	{field:please_detail_dates_you_were_diagnosed_discharged_and_any_treatments_you_received_or_still_receive_1677842330826}
Have you ever had any of these health conditions?	Checkboxes [ ] Cancer, cancer-in-situ, leukaemia, Hodgkin's disease or any other tumour [ ] Heart attack, irregular heart beat, cardiomyopathy, valve disorder or any other heart condition or heart surgery [ ] A stroke, TIA, brain haemorrhage or damage or surgery to your brain [ ] Had a cyst, growth or tumour in either your brain or spine? [ ] Multiple sclerosis, epilepsy, Parkinson's or any other disorder of the brain or nervous system [ ] Had any neurological condition or visual disturbance, for example epilepsy, multiple sclerosis, muscular dystrophy, cerebral palsy, motor neurone disease, Parkinson's disease, optic neuritis? (Please ignore long and short sightedness that's been corrected). [ ] A positive test, or are you waiting on the results of a test for, HIV, AIDS or hepatitis B or C [ ] Diabetes or raised blood sugar [ ] Been admitted overnight to hospital or referred to a psychiatrist for mental illness, anorexia or bulimia? [ ] No	{field:have_you_ever_had_any_of_these_health_conditions_1684404742942:label}
If you have said yes to the above please provide further information, such as dates of starting/stopping treatment, and type of treatment you received.	Free text field	{field:if_you_have_said_yes_to_the_above_please_provide_further_information_1689695603487}
Which of the following diabetes related conditions do you have?	Checkboxes [ ] Type 1 or insulin dependent diabetes [ ] Type 2 or non-insulin dependent diabetes [ ] Gestational diabetes [ ] Borderline diabetes or pre-diabetes [ ] Impaired glucose tolerance [ ] Impaired fasting glucose [ ] Sugar in your urine [ ] Diabetes insipidus [ ] None of these or don't know	{field:client_type_of_diabetes}
Date you were diagnosed with diabetes	Free text field	{field:client_date_diagnosed_diabetes}
Please tell us more about your diabetes	Free text field	{field:client_diabetes_more_info}
In the last 5 years have you had any of these health conditions?	Checkboxes [ ] Raised blood pressure, cholesterol or chest pain [ ] Anaemia, blood clot or anything else affecting your blood [ ] A tumour, lump, cyst, polyp, growth, or any mole/naevus that has bled, changed in appearance or become painful? [ ] Asthma, sleep apnoea, emphysema, sarcoidosis or anything else affecting your lungs or breathing [ ] Crohn's, colitis, IBS, or anything else affecting your stomach, bowel or digestive system [ ] Kidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urine [ ] Anything affecting your liver, gall bladder or pancreas [ ] Lupus, fibromyalgia, gout or any type of arthritis, neck, back, spine or joint trouble, for example rheumatoid arthritis, sciatica? [ ] Any condition affecting your thyroid? [ ] Any condition affecting your ears or hearing, for example Meniere's disease, deafness? (Please ignore simple earache and ear infections that have resolved leaving no continuing hearing loss) [ ] Any condition affecting your eyes or vision, not wholly corrected by spectacles, lenses or laser treatment, for example cataracts, blindness? [ ] Females only – Any abnormal cervical smears or mammograms? [ ] Palpitations or irregular heartbeat, paralysis, numbness, persistent tingling or pins and needles, tremor or facial pain other than dental pain, memory loss, dizziness or balance problems? [ ] Any other illness, injury or disability that’s kept you off work for a continuous period of 2 weeks or more, for example stress, headaches, trapped nerve? [ ] No	{field:in_the_last_5_years_have_you_had_any_of_these_health_conditions_1684404777143:label}
If you have said yes to the above please provide further information, such as dates of starting/stopping treatment, and type of treatment you received.	Free text field	{field:if_you_have_said_yes_to_the_above_please_provide_further_information_1689695615846}
Please clarify which condition	Checkboxes [ ] Raised Blood Pressure [ ] Raised Cholesterol [ ] Chest Pain	{field:blood_pressure_cholesterol_chest_pain}
Have you had any of the following?	Checkboxes [ ] Kidney problems or protein in your urine [ ] Angina, a heart attack, a stroke, a TIA or blocked or narrowed arteries in your legs [ ] An ECG or heart test that was abnormal [ ] Chest pain that required attendance at a medical facility [ ] Eye problems as a result of this condition [ ] None of the above	{field:issues_result_condition:label}
What type of consultation or investigation have you had or are you awaiting regarding this condition?	Checkboxes [ ] Have seen my GP [ ] Have seen a hospital or A&E doctor [ ] Waiting to see hospital doctor [ ] Have had an ECG [ ] Have had other tests or investigations [ ] Waiting to have tests or investigations, or waiting for results [ ] Have spent time in hospital as an inpatient [ ] None of the above	{field:investigations_result_condition:label}
When were you first told your blood pressure was raised?	Free text field	{field:date_told_blood_pressure_raised}
What were you told at your latest blood pressure review?	Checkboxes [ ] Advised to start or increase treatment [ ] Advised to review in the next 6 months [ ] Advised to review after 6 months [ ] Was referred to a specialist [ ] I was told that I didn't need to be seen again [ ] None of the above	{field:told_latest_blood_pressure_review}
Please tell us more about your raised blood pressure	Free text field	{field:raised_blood_pressure_more_info}
When were you first told your cholesterol was raised?	Free text field	{field:date_told_cholesterol_raised}
Please tell us more about your raised cholesterol	Free text field	{field:raised_cholesterol_more_info}
What were you told was the cause of your chest pain?	Checkboxes [ ] Heart attack, angina, blocked or narrow arteries [ ] Another heart condition [ ] Blood clot on the lung (pulmonary embolism) [ ] Chest infection [ ] Another chest or lung condition [ ] Anxiety or stress [ ] Muscular or joint pain [ ] Indigestion or dyspepsia [ ] Heartburn or acid reflux [ ] Hiatus hernia [ ] Other cause [ ] No cause found [ ] Don't know	{field:cause_of_chest_pain}
In the last 3 years, have you taken treatments, been asked to attend a follow up review, or advised to see a specialist, have a scan or investigation? You don't need to include things you've already told us about	Checkboxes [ ] I've taken or been prescribed treatment for 4 weeks or more [ ] I've been asked to attend a follow-up or regular reviews with a GP, hospital or clinic [ ] I've been advised to see a specialist or to have any tests, scans, investigations or counselling [ ] No	{field:in_the_last_3_years_have_you_taken_treatments_been_asked_to_attend_a_follow_up_review_or_advised_to_see_a_specialist_have_a_scan_or_investigation_you_don_t_need_to_include_things_you_ve_already_told_us_about_1684404939968:label}
If you have said yes to the above please provide further information.	Free text field	{field:if_you_have_said_yes_to_the_above_please_provide_further_information_1676886807350}
Have you had any of these symptoms in the last 3 months, even if you haven't seen a doctor? You don't need to include things you've already told us about	Checkboxes [ ] Any lump, growth or hardening affecting either testicle or the breast [ ] Bleeding from the bowel or a change in bowel habit [ ] A cough lasting more than 3 weeks [ ] A fit or seizure [ ] A mole or skin blemish which has changed in appearance [ ] Unexplained changes with walking, movement or mobility, numbness or tingling, mental functioning, or changes to your vision [ ] No	{field:have_you_had_any_of_these_symptoms_in_the_last_3_months_even_if_you_haven_t_seen_a_doctor_you_don_t_need_to_include_things_you_ve_already_told_us_about_1684404982730:label}
If you have said yes to the above please provide further information.	Free text field	{field:if_you_have_said_yes_to_the_above_please_provide_further_information_1676886832791}
Do you have any outstanding test, investigations or appointment for any health reason?	Free text field	{field:do_you_have_any_outstanding_test_investigations_or_appointment_for_any_health_reason_1727193734980}
Is there anything about your health that you’re yet to see the Dr about?	Free text field	{field:is_there_anything_about_your_health_that_you_re_yet_to_see_the_dr_about_1727193845074}
Covid-19	Checkboxes [ ] I've been treated at hospital for Coronavirus [ ] I've experienced symptoms of Coronavirus that have lasted longer than 12 weeks (known as Long-COVID) [ ] Neither of these	{field:covid-19_1676886657404}
Do you consume Alcohol?	Single Selection: > Yes > No	{field:do_you_consume_alcohol_1676886930389}
Lager/beer drinks consumed per week	Free text field	{field:lager_beer_drinks_consumed_per_week_1684491987641}
Spirits consumed per week	Free text field	{field:spirits_consumed_per_week_1684491998583}
Large wine consumed per week	Free text field	{field:large_wine_consumed_per_week_1684492008606}
Small wine consumed per week	Free text field	{field:small_wine_consumed_per_week_1684492015357}
Other alcoholic beverages consumed per week	Free text field	{field:other_alcoholic_beverages_consumed_per_week_1684492024517}
Have you been advised to cut down/stop drinking alcohol, attended/referred to support specialists, or ever used recreational drugs?	Checkboxes [ ] I've been advised by a medical professional to cut down or stop drinking alcohol [ ] I've attended, or been referred, for alcohol or drug specialist support such as Alcoholics or Narcotics Anonymous [ ] I've previously used recreational drugs in my lifetime (over 10 years ago) [ ] I've previously used recreational drugs in the last 10 years [ ] None of these	{field:have_you_been_advised_to_cut_down_stop_drinking_alcohol_attended_referred_to_support_specialists_or_ever_used_recreational_drugs_1684854514064}
Drug use in the last 10 years	Checkboxes [ ] Cannabis (unless prescribed by a health professional). You don't need to answer this question 'Yes' if you use or have used CBD oil only. [ ] Recreational drugs [ ] Any psychoactive substance including drugs previously known as 'legal highs' [ ] Any recreational drugs substitutes, for example, methadone [ ] Anabolic steroids (or any performance enhancing drugs) not prescribed by a doctor [ ] Been addicted to, misused or overused any medication whether prescribed by a doctor or not	{field:drug_use_in_the_last_10_years_1725642701077}
If you have said yes to the above please provide further information.	Free text field	{field:if_you_have_said_yes_to_the_above_please_provide_further_information_1676887300423}
Are you involved in any of these activities?	Checkboxes [ ] Armed forces (including reserves) [ ] Martial arts or combat sports [ ] Motor car or motorcycle sport [ ] Mountaineering or rock climbing [ ] Private flying, gliding or parachuting [ ] Sailing at sea or powerboat racing [ ] Scuba diving [ ] Underwater diving [ ] Caving or Potholing [ ] BASE Jumping [ ] Any other extreme sport, for example bungee jumping, canyoning, white water rafting [ ] None of these	{field:are_you_involved_in_any_of_these_activities_1684405350504:label}
Please detail any other dangerous pursuits you're involved with, not listed above.	Free text field	{field:please_detail_any_other_dangerous_pursuits_you_re_involved_with_not_listed_above_1677842446139}
Have you been banned or convicted for driving offences, or ride a motorbike or similar?	Checkboxes [ ] I've been banned from driving or convicted of dangerous or careless driving in the last 5 years [ ] I ride a motorbike, scooter or moped on the road [ ] No	{field:have_you_been_banned_or_convicted_for_driving_offences_or_ride_a_motorbike_or_similar_1684405502744}
Have you lived, worked or travelled outside the UK or European Union in the last 3 years, or do you have any plans to do so in the next year?	Single Selection: > Yes > No	{field:have_you_lived_worked_or_travelled_outside_the_uk_or_european_union_in_the_last_3_years_or_do_you_have_any_plans_to_do_so_in_the_next_year_1676887375093}
If you have said yes to the above, please provide further information	Free text field	{field:if_you_have_said_yes_to_the_above_please_provide_further_information_1676887505639}
GP Surgery Name	Free text field	{field:gp_surgery_name_1676887626646}
GP Address	Free text field	{field:gp_address_1676887645517}
GP Telephone Number	Free text field	{field:gp_telephone_number_1676887669773}
GP Name (if known)	Free text field	{field:gp_name_if_known_1676887686445}
Please detail anything else you feel may be relevant to your application	Free text field	{field:please_detail_anything_else_you_feel_may_be_relevant_to_your_application_1677844968920}

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