Pre-assessment Questionnaire

1 Personal Details
2 Insurance & Health
Personal Details
Gender:
What is your citizenship status?
Personal Health and Insurance History
Insurance History
Have you had an insurance application (for IP, Life, TPD, or Trauma) declined or have you received or made a claim for any sickness, injury, or disabilities benefits?
Family History
Have any of your immediate family been diagnosed with cystic fibrosis, familial polyposis of bowel, Huntington’s Disease, Multiple Sclerosis, Polycystic Kidney Disease, Muscular Dystrophy, Motor Neuron Disease?
Have any of your immediate family been diagnosed with Alzheimer’s or any form of dementia, Diabetes, had a health attack, had a bypass or a stent, high cholesterol, high blood pressure, stroke, any kinds of cancer including melanoma before the age of 60?
Personal Health and Activities
Have you smoked or used any nicotine containing products in the last 12 months?
Are you currently pregnant?
Do you take part in any hazardous pursuits or past times? (including any contact sports (boxing, MMA), sports involving speeds (mountain biking, motorsports), sports involving heights (bouldering, rock climbing, aerials), scuba diving etc?
Have you been diagnosed with any of these conditions? Respiratory Conditions Optical or Auditory conditions Diabetes Epilepsy Sleep Apnoea Heart conditions Autoimmune conditions (including Arthritis) Neurological Conditions Osteoporosis Lesions or abnormal lumps Cancer including BCC or SCCs
Have you been diagnosed with high blood pressure or high cholesterol?
Have you asked for or received advice, counselling or medication for your mental health or mental wellbeing from a health professional (GP, counsellor, psychologist, or psychiatrist)?
Have you experienced any back or neck pain in the last 5 years or have you ever been diagnosed with any spinal structural conditions including scoliosis, any disc issues, spine fractures, or suffered from a traumatic spine injury?
Have you suffered from any other bone, muscle, or joint injury in the last 5 years?
Have you ever been referred to a specialist? (not including for pregnancy or fertility)?
Are you waiting or are overdue for any test, consultations, surgery, or are currently being investigated for any conditions, or have you received any specialist referrals that you have not yet completed?
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  • OFFICE: Level 24/10 Eagle Street, Brisbane QLD 4000
  • POSTAL ADDRESS: GPO Box 12, Brisbane QLD 4001
Pre-Insurance Advice Questionnaire
Pre-Insurance Advice Questionnaire
Pre-Insurance Advice Questionnaire
Pre-Insurance Advice Questionnaire
All advice on this site is general in nature and does not take into account your personal circumstances. Please do not hesitate to contact one of our adviser accountants or financial planning advisers if you have a query that is specific to your circumstances.
ABN 11 248 978 295 Walshs Financial Planning Pty Ltd AFSL 432636 ABN 82 122 293 912 Corporate Authorised Representative No. 463774 of Walshs Finance Australian Credit Licence 459119

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