Health Questionnaire

The information you provide in this questionnaire assists your adviser in making recommendations appropriate to your circumstances. Applying for new or replacement insurance cover involves an assessment step called ‘underwriting’ where your health history, occupational duties, pastimes and other lifestyle activities are assessed by the insurer to determine if cover will be offered and on what terms. In some cases, we may use this information for a ‘Pre-assessment’ to field indicative terms and outcomes prior to providing a formal recommendation.

Your Details

Client 1

First Name(s)

Middle Name(s)

Surnames

Preferred Name(s)

Date of Birth

Gender

MaleFemale

Client 2

First Name(s)

Middle Name(s)

Surnames

Preferred Name(s)

Date of Birth

Gender

MaleFemale

Current Insurance Cover outside of Superannuation

Client 1

Life

TPD

Trauma

Child Trauma

Income Protection (pa)

Business Expenses (pa)

Please upload a recent superannuation statement

Browse

Client 2

Life

TPD

Trauma

Child Trauma

Income Protection (pa)

Business Expenses (pa)

Please upload a recent superannuation statement

Browse

Personal Questions

Client 1

Smoking Status

YesNo

If you have never been a smoker or quit over 12 months ago please leave blank and move onto next question. If you have ceased in the last 12 months, please provide the date.

Height

Weight

Client 2

Smoking Status

YesNo

If you have never been a smoker or quit over 12 months ago please leave blank and move onto next question. If you have ceased in the last 12 months, please provide the date.

Height

Weight

Past times and Pursuits

Client 1

Do you participate in any sport or activities?

YesNo

Provide details

Client 2

Do you participate in any sport or activities?

YesNo

Provide details

Employment

Client 1

What are the main duties of your occupation and what proportion of time is spent on them?

Do you travel for work?

YesNo

Provide details

Please provide any employee leave balances you are entitled to

Client 2

What are the main duties of your occupation and what proportion of time is spent on them?

Do you travel for work?

YesNo

Provide details

Please provide any employee leave balances you are entitled to

Medical History

Personal medical history

Client 1

Have you ever seen or been referred to a specialist in relation to any back / neck / joints / mental health issues?

YesNo

If Yes, please provide details including date of diagnosis, current treatment/medication and dosage, date of last symptoms, degree of recovery or if symptoms are ongoing

Any supporting evidence or information that will enhance accuracy of pre-assessment(i.e. reports, x-rays, consultations)

Please upload supporting documents

Browse

Does your medical record reflect any conditions diagnosed, investigated or where you have been referred to a specialist for any other medical issues (such as but not limited to Cardiovascular, Respiratory Disorders, Cancer, Blood or Organ conditions etc)?

YesNo

If Yes, please provide details including date of diagnosis, current treatment/medication, date of last symptoms, latest test results if known, details of any medications and dosages, degree of recovery or if symptoms are ongoing.

Any supporting evidence or information that will enhance accuracy of pre-assessment(i.e. histology report, x-rays, blood test results)

Please upload supporting documents

Browse

Have you ever discussed with your doctor or sought medical advice, counselling, or treatment for use of any drugs or medications not prescribed by a medical practitioner, including recreational and designer drugs?

YesNo

NB disclosing prior drug use does not automatically prevent you from obtaining cover as each insurer assesses the information slightly differently.

Please provide the following details that would exist on your medical history:

What are the types of recreational drugs you have used?

What was the period of use (approximate dates from and to etc.)

Have you ever had any health condition or impairment relating to the use of drugs?

When did you seek medical treatment or advice or receive a referral for drug counselling?

Have you ever been treated on a methadone or other controlled withdrawal program?

Have you ever taken time off work because of your alcohol or drug use or have your working duties ever been affected or restricted in any way?

YesNo

Are you now drug-free?

Yes No

When did you stop?

Are you planning to, or have you had a genetic test?

YesNo

Client 2

Have you ever seen or been referred to a specialist in relation to any back / neck / joints / mental health issues?

YesNo

If Yes, please provide details including date of diagnosis, current treatment/medication and dosage, date of last symptoms, degree of recovery or if symptoms are ongoing

Any supporting evidence or information that will enhance accuracy of pre-assessment(i.e. reports, x-rays, consultations)

Please upload supporting documents

Browse

Does your medical record reflect any conditions diagnosed, investigated or where you have been referred to a specialist for any other medical issues (such as but not limited to Cardiovascular, Respiratory Disorders, Cancer, Blood or Organ conditions etc)?

YesNo

If Yes, please provide details including date of diagnosis, current treatment/medication, date of last symptoms, latest test results if known, details of any medications and dosages, degree of recovery or if symptoms are ongoing.

Any supporting evidence or information that will enhance accuracy of pre-assessment(i.e. histology report, x-rays, blood test results)

Please upload supporting documents

Browse

Have you ever discussed with your doctor or sought medical advice, counselling, or treatment for use of any drugs or medications not prescribed by a medical practitioner, including recreational and designer drugs?

YesNo

NB disclosing prior drug use does not automatically prevent you from obtaining cover as each insurer assesses the information slightly differently.

Please provide the following details that would exist on your medical history:

What was the period of use (approximate dates from and to etc.)

What are the types of recreational drugs you have used?

Have you ever had any health condition or impairment relating to the use of drugs?

When did you seek medical treatment or advice or receive a referral for drug counselling?

Have you ever been treated on a methadone or other controlled withdrawal program?

Have you ever taken time off work because of your alcohol or drug use or have your working duties ever been affected or restricted in any way?

YesNo

Are you now drug-free?

Yes No

When did you stop?

Are you planning to, or have you had a genetic test?

YesNo

Family medical history

Client 1

Details of any immediate family members diagnosed with an illness

YesNo

(e.g. heart disease, cancer, MS, diabetes etc.)

Please detail family member, their condition(s) and tell us at what age they were diagnosed.

Client 2

Details of any immediate family members diagnosed with an illness

YesNo

(e.g. heart disease, cancer, MS, diabetes etc.)

Please detail family member, their condition(s) and tell us at what age they were diagnosed.

Disclosures and Privacy

I/We confirm that

Privacy

Keystone Wealth will collect personal and possibly sensitive information from you for the purpose of identifying and reviewing your financial and lifestyle objectives to enable the delivery of financial services and advice.

I understand providing the requested information is voluntary and if I choose not to provide this information Keystone Wealth is unable to provide accurate quoting or insurance recommendations. I have read the privacy collection notice and am aware of Keystone Wealth's Privacy Policy.

The information you provide, and any recommendations made will be kept on file. You are entitled to request reasonable access to any information held about you. It is also important to understand that we reserve the right to appoint another authorised representative from time to time. In these circumstances, we will write to you advising you of the change.

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Information Provided is Accurate

Keystone Wealth can hold my personal information; provided in this document is complete and accurate to the best of your knowledge.

It is your responsibility to provide accurate and appropriate information to allow the financial adviser to have reasonable grounds for making recommendations. We accept no liability for any advice given on the basis of inaccurate or incomplete information supplied by you.

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Provision of Health Information

Keystone Wealth may also need to collect and retain the following types of sensitive information;

Health and medical information (for example, medical checks or consultation reports);
Lifestyle and pastime information;
Information regarding your physical attributes, capacity and activity.

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Financial Services Guide

Please read the FPAA Financial Services Guide (FSG) dated Version 30th June 2022 for further Information. If you would like an additional copy of the current FSG please ask your Adviser. You can also access the FSG on our website www.keystonewealth.com.au.

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Signature

Client 1

Signature

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Client 2

Signature

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