Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI

How to use your – “Clinical Intelligence Questioning” Tool This screen is your “Homepage”, to return to this page at anytime click the CIQ Logo in the top left hand corner of any page. By clicking on the 1 st letter of the condition from the Alpha sequence below, you will be taken to a list of conditions. Click on the relevant condition that applies to your customer and you will be taken to the specific additional questions required to underwrite your customer. REMEMBER! These questions are in required in ADDITION to the standard questions under the section 7 of the Application Form. abcdefghijklmnopqrst uvwxyz Useful Reference Materials & Forms Yellow “Speech Bubbles” within CIQ alert you to critical information or action required C QI

Useful Reference Materials & Forms C QI CANCER Click here to be taken to the Cancer Statement to be printed and completed by the Dr who has treated the client. DIABETES Click here to be taken to the Diabetes Statement to be printed and completed by the Dr who has treated the client.

A – D Conditions Acne Allergic Rhinitis / Hayfever Asthma BPH Cataract Colonic Polyps Contact Dermatitis / Eczema Diabetes Mellitus – Type 2 Diverticular Disease Cholesterol (High) Detached Retina / Retinal Detachment Click on the condition to access the questions you need to ask your client: - C QI ACL Cancer Cold Sores (caused by Herpes Simplex)

E – H Conditions Endometriosis Eczema / Contact Dermatitis Epilepsy Fibrocystic Breast Disease Fibroids Haemorrhoids / Piles Gall Stones Gastritis Genital Herpes Glaucoma Gout Hayfever / Allergic Rhinitis Hiatus Hernia High Cholesterol Hypertension Hyperthyroidism Hypothyroidism C QI Hepatitis A Click on the condition to access the questions you need to ask your client: -

I – L Conditions Inguinal Hernia IBS – Irritable Bowel Syndrome Kidney or Ureter Stones (Calculus) C QI Click on the condition to access the questions you need to ask your client: -

M – P Conditions Malaria Migraine Miniscal Tears Moles Osteoarthritis Osteoporosis Peptic Ulcer Disease Psoriasis C QI Click on the condition to access the questions you need to ask your client: - Otitis Media

Q – T Conditions Reflux Oesophagitis (without hiatus hernia)Reflux Oesophagitis (without hiatus hernia) Retinal Detachment / Detached Retina Rotator Cuff Rupture of knees Sebaceous Cyst C QI Shingles / Herpes Zoster Click on the condition to access the questions you need to ask your client: -

U – Z Conditions C QI There are currently no conditions within the U to Z range. Click on the condition to access the questions you need to ask your client: -

Specific Cancers Bladder Cancer Basal Cell Carcinoma Bone Cancer Brain Cancer Colorectal Cancer Kidney Cancer Leukaemia Liver Cancer Lung Cancer C QI Breast Cancer Ovarian Cancer Oesophageal Cancer Pancreatic Cancer Prostate Cancer Stomach Cancer Uterine Cancer Squameous cell carcinoma Melanoma Non – Hodgkin's Lymphoma Click on the condition to access the questions you need to ask your client: - Remember, in cases where the client has been symptom and treatment free for the required time, click the cancer symbol to be taken to the “Cancer Statement”.

ACL – Anterior Cruciate Ligament Which knee is affected? Have you had an operation on the knee? Do you have any symptoms or problems at the moment? C QI This condition refers to Question 8 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Acne How long have you been suffering from acne? Is your acne caused by any other condition? E.g. hormone imbalance What treatment has been given – now or in the past? C QI This condition refers to Question 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Allergic Rhinitis / Hayfever When did you first have symptoms? Do you take any regular medication? If so, what do you take and how often? C QI This condition refers to Question 3 of the Confidential Medical History. Do you know what causes your Hayfever or allergic rhinitis? (e.g. dust, grass, pollen) Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Asthma How long have you had asthma? Have you ever been admitted to hospital for your asthma? Do you take or have you taken any medication, either now or in the past? C QI This condition refers to Question 3 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

BPH – Benign Prostatic Hyperplasia Have you had an operation for your Benign Prostatic Hyperplasia? What was the procedure that was carried out, and when did you have it? C QI This condition refers to Question 9 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Breast Cancer C QI This condition refers to Question 5 of the Medical History. Have you been symptom and treatment free from your cancer for more than 10 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Cataract Which eye do you have / had you had the cataract in (or is it both)? Have you had any surgery for your cataract(s)? Which eye was it in, or was it in both? Do you have any treatment planned or expected? Which eye is it for, or is it for both? C QI This condition refers to Question 11 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Colonic Polyps When were symptoms first noticed? Have you had any investigations or received any treatment? E.g. colonoscopy and polyp removal? Do you have any further treatment planned or expected? C QI This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Contact Dermatitis / Eczema When were symptoms first noticed? C QI This condition refers to Question 6 of the Medical History. Have you received any treatment? Have you been given any medication, either currently or in the past? Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Diabetes Mellitus – Type 2 C QI This condition refers to Question 2 of the Medical History. Please ask the client’s Dr to complete Diabetes Medical Statement. – Click the Diabetes Symbol below for a copy:

Diverticular Disease When were you diagnosed? How were you diagnosed? What symptoms have you had in the past? What current symptoms do you have? Do you have any treatment planned or expected? C QI This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Endometriosis Do you currently have any symptoms? Other than surgery, have you had any treatment? Has any surgery been performed? e.g. hysterectomy (removal of uterus), hysterectomy and oopherectomy (removal of uterus and fallopian tubes) C QI This condition refers to Question 9 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Epilepsy Have you had a seizure in the last 2 years? What medication(s) do you take? Is the epilepsy controlled by more than 1 type of medication? Is the epilepsy secondary to another condition? C QI This condition refers to Question 7 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Fibrocystic Breast Disease C QI This condition refers to Question 5 or 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form.

Fibroids Do you currently have fibroids or any symptoms? Are you currently receiving any treatment, or are you taking any medication? Do you expect to have any treatment? What treatment, if any, has been given in the past? C QI This condition refers to Question 9 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Gall Stones Do you have current symptoms? Have you had any surgery - e.g. removal of gall bladder? If so, when? Do you have any treatment planned or expected? C QI This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Gastritis What symptoms do you currently have? What symptoms have you had in the past? What treatment has been received? Are you currently on any medication? What medication have you received in the past? C QI This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Genital Herpes When were the symptoms first noticed? What treatment has been received to date? Is any treatment planned or expected? C QI This condition refers to Question 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Glaucoma When was glaucoma diagnosed? Have you had any surgery? If so, what type of surgery did you have and when did you have it? Do you have any further treatment planned or expected? C QI This condition refers to Question 11 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Gout Does your gout affect your heart or liver? Have you had any symptoms in the last 2 years? Are you currently taking or have you taken any medication in the last 2 years? Are you currently receiving any treatment? Do you have any treatment planned? C QI This condition refers to Question 8 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Haemorrhoids / Piles Have you had any symptoms or received any treatment in the last 2 years? What treatment have you receive? (eg banding, injecting) When did you receive it? Do you have any current symptoms? C QI This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Hiatus Hernia When were you diagnosed with hiatus hernia? Have you had any surgery? If yes, when was the surgery? Do you have any current symptoms? Are you having any treatment, or do you have treatment planned? C QI This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

High Cholesterol When were you diagnosed with high cholesterol? Are you taking any medication now or have you taken any in the past? Do you have any further treatment planned? This condition refers to Question 10 of the Medical History. C QI Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Hypertension When were you diagnosed with high blood pressure? Have you ever been admitted to hospital because of your high blood pressure? Are you currently on any medication or have you been on medication in the past? If you are currently taking medication – what are you taking? C QI This condition refers to Question 1 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Hyperthyroidism Have you had any symptoms or treatment in the last 3 years? What medication do you currently take? Do you have any further treatment or any surgery planned? C QI This condition refers to Question 2 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Hypothyroidism When were you diagnosed with an underactive thyroid? Have you had any surgery to remove your thyroid gland? What medication have you taken in the past? What medication are you currently taking? C QI This condition refers to Question 2 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

IBS / Irritable Bowel Syndrome C QI This condition refers to Question 4 of the Medical History. Have you had any symptoms, treatment or consultations in the last 2 years? If so, please provide full details. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Inguinal Hernia C QI This condition refers to Question 4 of the Medical History. What treatment have you received in the past? Do you have any further treatment expected or planned? Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Kidney or Ureter Stones (Calculus) C QI This condition refers to Question 9 of the Medical History. Have you had symptoms or treatment in the last 5 years? Please provide full details. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Malaria Are you currently receiving treatment for malaria? What symptoms or treatment have you had in the last year? Do you suffer from any complications of a malaria infection? C QI This condition refers to Question 10 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Malignant Melanoma C QI This condition refers to Question 5 of the Medical History. Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Migraine C QI This condition refers to Question 7 of the Medical History. Are you currently taking any medication? Have you taken any medication in the past? Please give full details of the types and frequency of the medication. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Miniscal Tears Which knee is affected – or are both affected? Have you had surgery to the affected knee(s). If so, what surgery have you had? Do you have any current symptoms? Do you have any treatment planned or expected? C QI This condition refers to Question 8 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Moles Have you ever had mole mapping? Have you ever had a benign mole or moles removed? Please give details. Have you ever been diagnosed with dysplastic naevi syndrome? C QI This condition refers to Question 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Non-Hodgkin's Lymphoma C QI This condition refers to Question 5 of the Medical History. Have you been symptom and treatment free from your cancer for more than 10 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Osteoarthritis Which joint or joints are affected? Have you had any surgery? Please provide full details. If you have had surgery have you had metal on metal hip replacement or hip resurfacing? C QI This condition refers to Question 8 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Osteoporosis Have you suffered any fractured bones? If so, please provide full details. C QI This condition refers to Question 8 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Otitis Media Have you had any treatment or symptoms in the last 2 years? C QI This condition refers to Question 11 of the Medical History. If yes, please provide full details including, treatment received and dates. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Peptic Ulcer Disease Is the ulcer still present? If not, when did you last experience symptoms or have treatment? C QI This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Psoriasis C QI This condition refers to Question 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form.

Reflux Oesophagitis (without Hiatus Hernia) C QI Is there a secondary condition causing your reflux for example a hiatus hernia? This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Retinal Detachment C QI This condition refers to Question 11 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form.

Rotator Cuff Have you had surgery? If so, when? Do you have any current symptoms? C QI This condition refers to Question 8 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Rupture of knees C QI This condition refers to Question 8 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form.

Sebaceous Cyst Do you currently have a sebaceous cyst? If you have had a sebaceous cyst in the past, what treatment have you had? C QI This condition refers to Question 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Squameous cell carcinoma This condition refers to Question X of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Stomach Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Uterine Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Basal Cell Carcinoma This condition refers to Question 5 of the Medical History. Have you been symptom and treatment free from your cancer for more than 5 years? C QI If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Bladder Cancer C QI This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Bone Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Brain Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Cold Sores (caused by the Herpes Simplex virus) C QI This condition refers to Question 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form.

Colorectal Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Hepatitis A Are you currently undergoing treatment, or have any complications? C QI This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Herpes Simplex Do you currently have herpes simplex, or do you have a history of it? Please provide details. C QI This condition refers to Question 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Herpes Zoster / Shingles Is this condition present or do you have ongoing complications? How many episodes have you had? Have you fully recovered? C QI This condition refers to Question 6 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Impaired Glucose Tolerance / pre Diabetes C QI This condition refers to Question 2 of the Medical History. When was the condition diagnosed? Do you take or have you taken any medication either now or in the past? Have you had any other treatment – in the past? Do you have any treatment planned or expected? Ask the 4 standard questions on the Additional Information page of the Application Form. Now obtain the answers to the supplementary questions displayed here.

Kidney Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Leukaemia This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Liver Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Lung Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Oesophageal Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Ovarian Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Pancreatic Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.

Prostate Cancer This condition refers to Question 5 of the Medical History. C QI Have you been symptom and treatment free from your cancer for more than 5 years? If no, answer the 4 standard questions on the Additional Information page of the Application Form. If yes, please ask the clients treating Dr to complete the Cancer Medical Statement, available by clicking the icon.