Clinical Intelligence Questioning for Brokers & Distributors

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

How to use your – “Clinical Intelligence Questioning” Tool
This screen is your “Homepage”, to return to this page at anytime click the top of the CIQ Logo in the top left hand corner of any page. Clicking on the CIQ letters will take you to the next page. By clicking on the 1st 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 required in ADDITION to the standard questions under section 7 of the Application Form. a b c d e f g h i j k l m n o p q r s t u v w x y z Yellow “Speech Bubbles” within CIQ alert you to critical information or action required Decline List Useful Reference Materials & Forms

Useful Reference Materials & Forms
Q I Useful Reference Materials & Forms CANCER Click on symbol to be taken to the Cancer Statement to be printed and completed by the Dr who has treated the client. DIABETES Click on symbol to be taken to the Diabetes Statement to be printed and completed by the Dr who has treated the client. CARDIAC ARRHYTHMIA Click on symbol to be taken to the Cardiac Statement to be printed and completed by the Dr who has treated the client.

C Q I A – D Conditions Click on the condition to access the questions you need to ask your client: - Acid reflux (Reflux Oesophagitis) Cataract ACL – Anterior Cruciate Ligament Celiac/Coeliac Disease Acne Cold Sores (caused by Herpes Simplex) Adenoiditis (Adenoidectomy) Cholesterol (High) Allergic Rhinitis / Hayfever Colonic Polyps Ankle / Foot Sprain / Strain Contact Dermatitis / Eczema Asthma Detached Retina / Retinal Detachment Atrial Fibrillation (AF) Diabetes Mellitus – Type 2 Back Pain Diverticular Disease Benign Prostatic Hyperplasia (BPH) Breast Lump (non cystic ) / Fibroadenoma Cancer

Decline List C Q I Acromegaly Haemophilia A & B Sebastian Syndrome
Addison Disease Interstitial Pulmonary Fibrosis Silicosis of the lungs Alzheimer’s Disease Klinefelter Syndrome Tetraplegia Amyotrophic Lateral Sclerosis Liver Cirrhosis Thalassemia Major Ankylosing Spondylitis Lupus Erythematosus Turner’s Syndrome Asbestosis Metastic Cancer Von Recklinghausen’s Disease Cerebral Palsy Mixed Connective Tissue Disorder Wegener’s Granulomatosis Chronic Constrictive Pericarditis Morbid Obesity Chronic Renal Insufficiency Multiple Myelomas Cor Pulmonale Multiple Sclerosis Creutzfeld-Jacob Disease Organ Transplant (status post, except for cornea transplant) Cystic Fibrosis Paget’s Disease (Osteodystrophia Deformans) Diabetes Insipidus Parkinson’s Disease Down’s Syndrome Pemphigus Vulgaris Dwarfism of pituitary cause Pariartheritis Nodosa Dialysis treatment Pneumoconiosis Fancon’s Anaemia Polycystic Renal Disease Felty’s Syndrome Polycytemia Fibrocystic Disease of the Pancreas/Mucoviscidosis Polymyositis Fibromalgia Porphyria Fiedrich’s Ataxia Quadriplegia Galactosemia Reiter’s Syndrome Gardner’s Syndrome Schizophrenia Granuloma Eosinophile Scleroderma/Progressive Systematic Sclerosis (PSS) Hemochromatosis (diagnosis of)

C Q I E – H Conditions Click on the condition to access the questions you need to ask your client: - Eczema / Contact Dermatitis Haemorrhoids / Piles Epilepsy / Seizures Hayfever / Allergic Rhinitis Fibroadenoma / Breast Lump Heartburn (Reflux Oesophagitis) Fibrocystic Breast Disease Helicobacter Pylori Fibroids Hepatitis A Foot / Ankle Sprain / Strain Herpes Simplex (other than cold sore) Fungal Infections – external Herpes Zoster / Shingles Gall Stones Hiatus Hernia Gastritis High Cholesterol Genital Herpes Hypertension (High Blood Pressure) Glaucoma Hyperthyroidism (Over active Thyroid) Gout Hypothyroidism (Under active Thyroid)

C Q I I – L Conditions Click on the condition to access the questions you need to ask your client: - IBS – Irritable Bowel Syndrome Impaired Glucose Tolerance / Pre-Diabetes Inguinal Hernia Kidney or Ureter Stones (Calculus) Knee Disorders: ACL – Anterior Cruciate Ligament Knee Sprain (ligament) other than ACL Knee Strain Meniscal Tears Rupture of knees Leg Sprain / Strain

C Q I M – P Conditions Click on the condition to access the questions you need to ask your client: - Malaria Paroxysmal Atrial Fibrillation Migraine Peptic Ulcer Disease Psoriasis Meniscal Tears Moles Osteoarthritis Osteoporosis Otitis Media Ovarian Cyst Palpitations

C Q I Q – T Conditions Click on the condition to access the questions you need to ask your client: - Reflux Oesophagitis (without hiatus hernia) Sinusitis Retinal Detachment / Detached Retina Supra Ventricular Tachycardia (SVT) Rotator Cuff Injury Thyroid Disorders Rupture of knees Tonsillitis (Tonsillectomy) Sebaceous Cyst Shingles / Herpes Zoster Shoulder Sprain / Strain

C Q I Thyroid Disorders Click on the condition to access the questions you need to ask your client: - Hyperthyroidism – Over active Hypothyroidism – Under active Other thyroid conditions – No loadings currently available

C Q I U – Z Conditions Click on the condition to access the questions you need to ask your client: - Urinary Tract Infection

C Q I Specific Cancers Click on the condition to access the questions you need to ask your client: - Basal Cell Carcinoma Non – Hodgkin's Lymphoma Bladder Cancer Ovarian Cancer Oesophageal Cancer Pancreatic Cancer Prostate Cancer Stomach Cancer Uterine Cancer Squameous cell carcinoma 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”. Bone Cancer Brain Cancer Breast Cancer Colorectal Cancer Kidney Cancer Leukaemia Unlisted Cancer Liver Cancer Lung Cancer Melanoma

ACL – Anterior Cruciate Ligament
Q I ACL – Anterior Cruciate Ligament 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. Which knee is affected? Have you had an operation on the knee? If so, when (month and year) Do you have any ongoing symptoms or problems?

Knee sprain (ligament) other than ACL
Q I Knee sprain (ligament) other than ACL 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. Which knee is affected? Have you had an operation on the knee? If so, when (month and year) Do you have any ongoing symptoms or problems?

C Q I Knee Strain 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. Which knee is affected? Have you had an operation on the knee? If so, when (month and year) Do you have any ongoing symptoms or problems?

C Q I Leg Sprain / Strain 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. Which leg is affected? Have you had an operation on the leg? If so, when (month and year) Do you have any ongoing symptoms or problems?

Ankle / Foot Sprain / Strain
C Q I Ankle / Foot Sprain / Strain 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. Which ankle/foot is affected? Have you had an operation on the ankle/foot? If so, when (month and year) Do you have any ongoing symptoms or problems?

Acne C Q I 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. 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? Please provide start and stop dates for treatment (month and year)

Allergic Rhinitis / Hayfever
Q I Allergic Rhinitis / Hayfever This condition refers to Question 3 of the Confidential 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. When did you first have symptoms? Do you know what causes your Hayfever or allergic rhinitis? (e.g. dust, grass, pollen) Do you take any regular medication? If so, what do you take and how often?

C Q I Sinusitis This condition refers to Question 3 of the Confidential 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. When did you last have symptoms? Have you been advised that you may need surgery? How many episodes of sinusitis have you had?

C Q I Asthma 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. 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? Please provide dates (month and year)

BPH – Benign Prostatic Hyperplasia
Q I BPH – Benign Prostatic Hyperplasia 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. Have you had an operation for your Benign Prostatic Hyperplasia? What was the name of the procedure that was carried out, and when did you have it? (Month and year) Please provide details of your last PSA test result including date of test.

This condition refers to Question 5 of the Medical History.
Breast Cancer 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.

C Q I Cataract 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. Which eye do you have / did you have the cataract in (or is it both)? Have you had any surgery for your cataract(s)? Which eye was operated (or was it in both). When did the operation take place? (month and year) Do you have any treatment planned or expected? Which eye is it for (or is it for both)?

C Q I Colonic Polyps 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. When were symptoms first noticed? (month and year) Have you had any investigations or received any treatment? E.g. colonoscopy and polyp removal? If so, when? (month and year) Do you have any further treatment planned or expected?

C Q I Ovarian Cyst 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. Is the member in question postmenopausal? Is the cyst present? If so, please provide details of treatment planned or expected. Have you suffered from previous cysts? How were each treated and when did you experience these? Is there any underlying cause to the cyst/s, such as Endometriosis or Polycystic Ovaries?

Contact Dermatitis / Eczema
Q I Contact Dermatitis / Eczema 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. When were symptoms first noticed? (month and year) Have you received any treatment? If yes, what treatment did you receive and when? (month and year)

Diabetes Mellitus – Type 2
C Q I Diabetes Mellitus – Type 2 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 C Q I
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. When were you diagnosed? (month and year) 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 Q I Epilepsy 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. 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?

Fibrocystic Breast Disease
Q I Fibrocystic Breast Disease 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.

Fibroadenoma / Breast Lump (non cystic)
Q I Fibroadenoma / Breast Lump (non cystic) 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.

C Q I Fibroids 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. 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? Please provide dates of treatment. (month and year)

C Q I Gall Stones 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. Do you have current symptoms? Have you had any surgery - e.g. removal of gall bladder? If so, when (month and year)? Do you have any treatment planned or expected?

C Q I Gastritis 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. What, if any, investigations have been carried out? Please include details of results and confirmation of a final diagnosis/underlying cause, if known. If a diagnosis has not been made, what (in your treating Dr’s opinion) was the suspected cause of the gastritis? What symptoms, both current and previous have you experienced? Please include dates (month and year) What treatment has been received to date? Please include details of any medication. Is there any ongoing treatment or follow-up planned?

Helicobacter Pylori This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form.

C Q I Genital Herpes 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. When were the symptoms first noticed? (month and year) What treatment has been received to date? Include stop and start dates of treatment (month and year) Is any treatment planned or expected?

C Q I Glaucoma 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. When was glaucoma diagnosed (month and year)? Have you had any surgery? If so, what type of surgery did you have and when did you have it (month and year)? Do you have any further treatment planned or expected?

Gout C Q I 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. Does your gout affect your heart or kidneys? If yes, please provide details When was the last time you had an acute attack (month and year)? 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?

Haemorrhoids / Piles C Q I
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. Have you had any symptoms or received any treatment in the last 3 years? What treatment have you receive? (eg banding, injecting) When did you receive it (month and year)? Do you have any current symptoms?

C Q I 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. When were you diagnosed with hiatus hernia (month and year)? Have you had any surgery? If yes, when was the surgery (month and year)? Do you have any current symptoms? Are you having any treatment, or do you have treatment planned?

C Q I High Cholesterol 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. When were you diagnosed with high cholesterol (month and year)? Are you taking any medication now or have you taken any in the past? If so, what medication did you / are you taking Do you have any further treatment planned?

C Q I Hypertension 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. When were you diagnosed with high blood pressure (month and year)? Have you ever been admitted to hospital because of your high blood pressure? If so when, and how long for? Are you currently on any medication or have you been on medication in the past? If you are currently taking medication – what medication did you take / are you taking?

C Q I Hyperthyroidism 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. 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 Q I Hypothyroidism 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. When were you diagnosed with an underactive thyroid (month and year)? Have you had any surgery to remove your thyroid gland? If so, what was the reason for the surgery and when did you have it (month and year)? What medication have you taken in the past? What medication are you currently taking?

IBS / Irritable Bowel Syndrome
C Q I IBS / Irritable Bowel Syndrome 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. Have you had any symptoms, treatment or consultations in the last 2 years? If so, please provide full details, including names of medication, start and stop dates of treatment (month and year).

C Q I Inguinal 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. What treatment have you received in the past? Please include dates of treatment (month and year). Which side was your hernia located (or was it both). Have you had a reoccurrence of your hernia? Do you have any further treatment expected or planned?

Kidney or Ureter Stones (Calculus)
Q I Kidney or Ureter Stones (Calculus) 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. Have you had symptoms or treatment in the last 5 years? Please provide full details, including type of treatment and dates of treatment (month and year).

C Q I Malaria 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. 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?

Malignant Melanoma 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.

C Q I Migraine 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. 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. When was the last time you took medication (month and year)?

C Q I Meniscal Tears 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. Which knee is affected – or are both affected? Have you had surgery to the affected knee(s). If so, what surgery have you had? When did you have surgery (month and year)? Do you have any current symptoms? Do you have any treatment planned or expected?

C Q I Moles 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. Have you ever had mole mapping? Have you ever had a benign mole or moles removed? Please give details including dates of treatment (month and year)? Have you ever been diagnosed with dysplastic naevi syndrome?

Non-Hodgkin's Lymphoma
C Q I Non-Hodgkin's Lymphoma 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.

C Q I Osteoarthritis 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. Which joint or joints are affected? Please include left, right or both. Have you had any surgery? Please provide full details including name of procedure, which joint and when (month and year). If you have had surgery have you had metal on metal hip replacement or hip resurfacing?

C Q I Osteoporosis 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. Have you suffered any fractured bones? If so, please provide full details including method of treatment (cast / surgery), date of treatment (month and year) and which bone was fractured (include left / right / both) If you have had surgery: Did you have any internal / external fixation? If yes, when was the fixation removed (month and year), or does it remain in place?

C Q I Otitis Media 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. Have you had any treatment or symptoms in the last 2 years? If yes, please provide full details including, treatment received and dates (month and year).

Peptic Ulcer Disease C Q I
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. Is the ulcer still present? If not, when did you last experience symptoms or have any treatment (month and year)?

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

Celiac/Coeliac Disease
Q I Celiac/Coeliac Disease This condition refers to Question 4 of the Medical History. Ask the 4 standard questions on the Additional Information page of the Application Form.

Reflux Oesophagitis (without Hiatus Hernia)
C Q I Reflux Oesophagitis (without 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. Is there a secondary condition causing your reflux for example a hiatus hernia?

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

C Q I Rotator Cuff 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. Have you had surgery? If so, when (month and year)? Do you have any current symptoms?

C Q I Back Pain 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. What is the underlying cause of the back pain? Have you had any pain down your legs associated with back pain? Have you had any numbness or weakness in one of both legs or around your buttock? Are you still suffering with back pain? Is this constant? Does this affect you more at night? What treatment has been received to date? Do you have any treatment planned or anticipated?

Shoulder Sprain / Strain
C Q I Shoulder Sprain / Strain 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. Have you had surgery? If so, when (month and year)? Do you have any current symptoms?

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

C Q I Sebaceous Cyst 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. Do you currently have a sebaceous cyst? If so, where is it located (include left / right / both)? If you have had a sebaceous cyst in the past, what treatment have you had and when (month and year)?

Squameous cell carcinoma
This condition refers to Question X 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.

Stomach Cancer 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.

Uterine Cancer 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.

Unlisted Cancer 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.

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? 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 This condition refers to Question 5 of the Medical History. C I Q 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. 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. 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)
Q I Cold Sores (caused by the Herpes Simplex virus) This condition refers to Question 6 of the Medical History. If any other symptom of herpes simplex, please follow guide for Herpes Simplex. For Cold Sore only - 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. 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.

C Q I Hepatitis A 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. Are you currently undergoing treatment, or have any complications?

C Q I Herpes Simplex 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. If only symptom of Herpes Simplex is Cold Sore, please follow guide for Cold Sore (Caused by Herpes Simplex virus). Do you currently have herpes simplex, or do you have a history of it? Please provide details including how the condition affected you, what treatment you received, dates of treatment (month and year) and details of any ongoing treatment or investigation.

Herpes Zoster / Shingles
C Q I Herpes Zoster / Shingles 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. Is this condition present or do you have ongoing complications? How many episodes have you had? Have you fully recovered?

Fungal Infections – external only
Q I Fungal Infections – external only 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. Is this condition present or do you have ongoing complications? How many episodes have you had? Have you fully recovered?

Urinary Tract Infection
Q I Urinary Tract Infection 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. Is this condition present or do you have ongoing complications? How many episodes have you had? Have you fully recovered?

Impaired Glucose Tolerance / pre Diabetes
Q I Impaired Glucose Tolerance / pre Diabetes 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:

Kidney Cancer 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.

Leukaemia 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.

Liver Cancer 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.

Lung Cancer 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.

Oesophageal Cancer 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.

Ovarian Cancer 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.

Pancreatic Cancer 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.

Prostate Cancer 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.

Adenoiditis (Adenoidectomy)
Q I Adenoiditis (Adenoidectomy) 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. When was the last time you had an attack of adenoiditis? (month and year) If you have had your adenoids removed, when did this happen (month and year)

Tonsillitis (tonsillectomy)
Q I Tonsillitis (tonsillectomy) 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. When was the last time you had an attack of tonsillitis? (month and year) If you have had your tonsils removed, when did this happen (month and year)

Atrial Fibrillation (AF)
C Q I Atrial Fibrillation (AF) This condition refers to Question 1 of the Medical History. Please ask the client’s Dr to complete Cardiac Arrhythmia Medical Statement. – Click the Cardiac Symbol below for a copy:

Palpitations Palpitations
C Q I This condition refers to Question 1 of the Medical History. Palpitations Please ask the client’s Dr to complete Cardiac Arrhythmia Medical Statement. – Click the Cardiac Symbol below for a copy: Palpitations

Paroxysmal Atrial Fibrillation (Paroxysmal AF)
C Q I Paroxysmal Atrial Fibrillation (Paroxysmal AF) This condition refers to Question 1 of the Medical History. Please ask the client’s Dr to complete Cardiac Arrhythmia Medical Statement. – Click the Cardiac Symbol below for a copy:

Supra Ventricular Tachycardia (SVT)
Q I Supra Ventricular Tachycardia (SVT) This condition refers to Question 1 of the Medical History. Please ask the client’s Dr to complete Cardiac Arrhythmia Medical Statement. – Click the Cardiac Symbol below for a copy:

Clinical Intelligence Questioning for Brokers & Distributors

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Clinical Intelligence Questioning for Brokers & Distributors

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