Quick Health Check Form

Insurance Company: Insurance Company field Policy Number/s: 1234566

Adviser name: Adviser name field

SECTION A – PERSONAL DETAILS

Surname: Surname field Given name/s: Given name field

DOB: 14/07/1982 Mobile: +61423679126

Street Address: Street Address field

State: New South

Suburb: Suburb field Postcode: 2170
Wales

SECTION B – REGULAR DOCTOR DETAILS

Name: Doctor name

Address: Doctor's address

Phone: +61423679126

How long have you been attending to this doctor?: attending Date of last consult: last consult
doctor field

Reason and outcome of last consult: reason last consult

Are you considering consulting or receiving any advice or

treatment from any doctor or other healthcare professional or Yes
seeking a medical examination, tests or an operation?

If “YES”, please provide details:

other doctor details
 dean client

Do you take any prescribed medication on a regular

Yes
basis?

If “YES”: What is the name, frequency and dosage of the medication? What is the reason for
the medication?
allegra

A. MEASUREMENTS

Chest Inspiration: 200cm Chest Expiration: 24cm

the chest expansion is less than 5cm, please comment as to cause.

special

Height (without shoes): 174cm Weight (clothed): 80kg

Abdomen at umbilicus:
Hip Measurement: 54cm
25cm

Calculate BMI = weight/(height )2 : 26.42

Has your weight changed significantly in the past 12

Yes
months?

If “YES”: Was it a gain or loss and how many kgs? Gain, 5kg. What was the reason for the
gain or loss? holiday
 B. CIRCULATORY SYSTEM

BLOOD PRESSURE: The diastolic level is to be taken at the cessation of all sound. If the first
systolic reading is above 135 or below 100, or the diastolic above 85 or below 60, two further
readings at 5 to 10-minute intervals are required. The recumbent position should be used where
possible.

Reading Systolic Diastolic

1st 1 1

2nd 2 2

3rd 3 3

Pulse Rate: 10 Pulse Character 10

C. GENITO-URINARY SYSTEM

Does the urine contain the following? Please write positive or negative.

Reflex testing (if

Result
required)

RIf positive, send for

Protein Negative
ACR and MSU

Blood Negative If positive, send for MSU

Glucose Negative If positive, send for MSU

If positive results in specimen, was the urine sample sent to

the lab for further testing?

Was the urine passed at the time of the examination? Yes

If Female, is the client menstruating? Yes

dean client
Your duty to take reasonable care

When applying for insurance, there is a legal duty to take reasonable care not to make a
misrepresentation to the Insurer before the contract of insurance is entered in to. A
misrepresentation is a false answer, an answer that is only partially true, or an answer which
does not accurately reflect the truth. If the duty is not met, this can have serious impacts on
your insurance. Your cover could be voided (treated as if it never existed), or its terms may be
changed. This may also result in a claim being declined or a benefit being reduced. Please note
that there may be circumstances where the Insurer later investigates whether the information
given to it was true. For example, it may do this when a claim is made.

Guidance for answering the questions in this form

When answering the questions in this form, please:

• Think carefully about each question before you answer. If you are unsure of the meaning of
any question, please ask us before you respond;
• Answer every question;
• Answer truthfully, accurately and completely. If you are unsure about whether you should
include information, please include it; and
• Review your application carefully before it is submitted. If someone else helped prepare
your application (for example, your adviser) please check every answer (and if necessary,
make any corrections) before the application is submitted.

Changes before your cover starts

Before your cover starts, we may ask about any changes that mean you would now answer our
questions differently. As any changes might require further assessment or investigation, it could
save time if you let us know about any changes when they happen.

If you need help

It is important that you understand your obligations and the questions asked. Please contact
your Insurer or financial adviser for help if you have difficulty understanding the process of
obtaining insurance or answering any questions.

Privacy Statement

Your insurance company and/or financial adviser has engaged Prestige Paramedical Group to
manage the collection of medical information about you for the purposes of enabling that
company to decide whether to offer you insurance cover. You authorise and consent to the
collection and full disclosure of medical information held by you or any third party to Prestige
Paramedical Group or an agent acting on behalf of Prestige Paramedical Group (including
registered health professionals conducting thisassessment) and your insurance company. Only
Prestige Paramedical Group’s staff and agents (including registered health professionals
conducting this assessment) dealing directly with your application will view your information and
we will ensure that all employees, agents, contractors and other persons withinour control
comply with the provisions of this Consent Form. Should you wish to view your information or
results at any time, you may do so by contacting your insurance company.

For further information about your privacy please go to

www.prestigeparamedical.com.au/privacy-policy
Signature of the Life Insured:

Date: 11/09/2023

Name and Qualifications of the Medical Examiner: Dean medical examiner

Signature of the medical examiner:

Date: 11/09/2023

02 9545 5444

PO Box 1994 ABN 24 169 019 792

Woolooware NSW 2230 prestigeparamedical.com.au

prestige@prestigeparamedical.com.au