Quick Health Check Form

Insurance Company Policy Number/s

Adviser name:

SECTION A – PERSONAL DETAILS

Surname: Given name/s:

DOB: Mobile:

Street Address:

Suburb: State: Postcode:

Occupation:

SECTION B – REGULAR DOCTOR DETAILS

Name:

Address:

Phone:

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

Reason and outcome of last consult:

Are you considering consulting or receiving any advice or treatment from any doctor or other
Yes No
healthcare professional or seeking a medical examination, tests or an operation?

If “YES”, please provide details:

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 Client Name:

Do you take any prescribed medication on a regular basis?

Yes No

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

What is the reason for the medication?

A. MEASUREMENTS

Chest Inspiration: cm Chest Expiration: cm

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

Height (without shoes): cm Weight (clothed): kgs

Hip Measurement: cm Abdomen at umbilicus: cm

Calculate BMI = weight/(height )2 :

• Has your weight changed significantly in the past 12 months? Yes No

If “YES”: Was it a gain or loss and how many kgs?

What was the reason for the gain or loss?

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

2nd

3rd

Pulse Rate: Pulse Character:

C. GENITO-URINARY SYSTEM

Does the urine contain the following? Please write positive or negative.
Result Reflex testing (if required)

Protein If positive, send for ACR and MSU

Blood If positive, send for MSU

Glucose If positive, send for MSU

If positive results in specimen, was the urine sample sent to the lab for further testing? Yes No

Was the urine passed at the time of the examination?

Yes No

If Female, is the client menstruating? Yes No

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 Client Name:

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

Or visit http://www.privacy.gov.au/

Signature of the Life Insured: Date:

Name and Qualifications of the Medical Examiner:

Signature of the medical examiner: Date:

02 9545 5444
PO Box 1994 ABN 24 169 019 792

Woolooware NSW 2230 prestigeparamedical.com.au

prestige@prestigeparamedical.com.au
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