Cover for pre-existing conditions

Clinical Intelligence Questioning for Brokers & Distributors

to open the tool, click to the next page…

C QI

How to use your – “Clinical Intelligence Questioning” Tool

• This screen is your “Homepage”, to return to this page at anytime click the CIQ Logo in the top left hand corner of any 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 in required in ADDITION to the standard questions under the 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

Useful Reference Materials & Forms

Yellow “Speech Bubbles” within CIQ alert you to critical

information or action required

C QI

Useful Reference Materials & FormsC QI

CANCERClick here to be taken to the Cancer

Statement to be printed and completed by the Dr who has treated the client.

DIABETESClick here to be taken to the Diabetes Statement to be printed and completed by the Dr who has treated the client.

A – D Conditions

• Acne

• Allergic Rhinitis / Hayfever

• Asthma

• BPH

• Cataract

• Colonic Polyps

• Contact Dermatitis / Eczema

• Diabetes Mellitus – Type 2

• Diverticular Disease

• Cholesterol (High)

• Detached Retina / Retinal Detachment

Click on the condition to access the questions you need to ask your client: -C QI

• ACL

• Cancer

• Cold Sores (caused by Herpes Simplex)

E – H Conditions

• Endometriosis

• Eczema / Contact Dermatitis

• Epilepsy

• Fibrocystic Breast Disease

• Fibroids

• Haemorrhoids / Piles

• Gall Stones

• Gastritis

• Genital Herpes

• Glaucoma

• Gout

• Hayfever / Allergic Rhinitis

• Hiatus Hernia

• High Cholesterol

• Hypertension

• Hyperthyroidism

• Hypothyroidism

C QI

• Hepatitis A

Click on the condition to access the questions you need to ask your client: -

I – L Conditions

• Inguinal Hernia

• IBS – Irritable Bowel Syndrome

• Kidney or Ureter Stones (Calculus)

C QIClick on the condition to access the

questions you need to ask your client: -

M – P Conditions

• Malaria

• Migraine

• Miniscal Tears

• Moles

• Osteoarthritis

• Osteoporosis

• Peptic Ulcer Disease

• Psoriasis

C QIClick on the condition to access the

questions you need to ask your client: -

• Otitis Media

Q – T Conditions

• Reflux Oesophagitis (without

hiatus hernia)

• Retinal Detachment / Detached Retina

• Rotator Cuff

• Rupture of knees

• Sebaceous Cyst

C QI

• Shingles / Herpes Zoster

Click on the condition to access the questions you need to ask your client: -

U – Z ConditionsC QI

There are currently no conditions within the

U to Z range.

Click on the condition to access the questions you need to ask your client: -

Specific Cancers

• Bladder Cancer

• Basal Cell Carcinoma

• Bone Cancer

• Brain Cancer

• Colorectal Cancer

• Kidney Cancer

• Leukaemia

• Liver Cancer

• Lung Cancer

C QI

• Breast Cancer

• Ovarian Cancer

• Oesophageal Cancer

• Pancreatic Cancer

• Prostate Cancer

• Stomach Cancer

• Uterine Cancer

• Squameous cell carcinoma

• Melanoma

• Non – Hodgkin's Lymphoma

Click on the condition to access the questions you need to ask your client: -

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”.

ACL – Anterior Cruciate Ligament

Which knee is affected?

Have you had an operation on the knee?

Do you have any symptoms or

problems at the moment?

C QIThis 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.

Acne

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?

C QIThis 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.

Allergic Rhinitis / Hayfever

When did you first have symptoms?

Do you take any regular medication?

If so, what do you take and how often?

C QIThis condition refers to Question 3 of

the Confidential Medical History.

Do you know what causes your Hayfever or allergic rhinitis?

(e.g. dust, grass, pollen)

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Asthma

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?

C QIThis 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.

BPH – Benign Prostatic Hyperplasia

Have you had an operation for your

Benign Prostatic Hyperplasia?

What was the procedure that was carried

out, and when did you have it?

C QIThis 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.

Breast CancerC QIThis 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.

Cataract

Which eye do you have / had you

had the cataract in (or is it both)?

Have you had any surgery for your

cataract(s)? Which eye was it in, or was it

in both?

Do you have any treatment planned or

expected? Which eye is it for, or is it for

both?

C QIThis 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.

Colonic Polyps

When were symptoms first noticed?

Have you had any investigations or

received any treatment?

E.g. colonoscopy and polyp removal?

Do you have any further treatment

planned or expected?

C QIThis 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.

Contact Dermatitis / Eczema

When were symptoms first noticed?

C QIThis condition refers to Question 6 of

the Medical History.

Have you received any treatment?

Have you been given any medication, either currently or in

the past?

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Diabetes Mellitus – Type 2C QI

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

When were you diagnosed?

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 QIThis 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.

Endometriosis

Do you currently have any

symptoms?

Other than surgery, have you had

any treatment?

Has any surgery been performed?

e.g. hysterectomy (removal of uterus),

hysterectomy and oopherectomy (removal

of uterus and fallopian tubes)

C QIThis 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.

Epilepsy

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?

C QIThis 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.

Fibrocystic Breast Disease C QI

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.

Fibroids

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?

C QIThis 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.

Gall Stones

Do you have current symptoms?

Have you had any surgery - e.g. removal

of gall bladder? If so, when?

Do you have any treatment planned

or expected?

C QIThis 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.

Gastritis

What symptoms do you currently

have?

What symptoms have you had in the

past?

What treatment has been received?

Are you currently on any medication?

What medication have you received

in the past?

C QIThis 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.

Genital Herpes

When were the symptoms first

noticed?

What treatment has been received to

date?

Is any treatment planned or

expected?

C QIThis 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.

Glaucoma

When was glaucoma diagnosed?

Have you had any surgery?

If so, what type of surgery did you have

and when did you have it?

Do you have any further treatment

planned or expected?

C QIThis 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.

Gout

Does your gout affect your heart or

liver?

Have you had any symptoms in the last 2

years?

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?

C QIThis 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.

Haemorrhoids / Piles

Have you had any symptoms or

received any treatment in the last 2

years?

What treatment have you receive?

(eg banding, injecting)

When did you receive it?

Do you have any current

symptoms?

C QIThis 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.

Hiatus Hernia

When were you diagnosed with

hiatus hernia?

Have you had any surgery?

If yes, when was the surgery?

Do you have any current symptoms?

Are you having any treatment, or do you

have treatment planned?

C QIThis 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.

High Cholesterol

When were you diagnosed with high

cholesterol?

Are you taking any medication now or

have you taken any in the past?

Do you have any further treatment

planned?

This condition refers to Question 10

of the Medical History.

C QI

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Hypertension

When were you diagnosed with high

blood pressure?

Have you ever been admitted to hospital

because of your high blood pressure?

Are you currently on any medication or have

you been on medication in the past?

If you are currently taking medication – what are

you taking?

C QIThis 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.

Hyperthyroidism

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 QIThis 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.

Hypothyroidism

When were you diagnosed with an

underactive thyroid?

Have you had any surgery to remove your

thyroid gland?

What medication have you taken in the

past?

What medication are you currently taking?

C QIThis 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.

IBS / Irritable Bowel SyndromeC QI

This condition refers to Question 4 of

the Medical History.

Have you had any symptoms, treatment or

consultations in the last 2 years?

If so, please provide full details.

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Inguinal HerniaC QIThis condition refers to Question 4 of

the Medical History.

What treatment have you received

in the past?

Do you have any further treatment

expected or planned?

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Kidney or Ureter Stones (Calculus)C QI

This condition refers to Question 9 of

the Medical History.

Have you had symptoms or

treatment in the last 5 years?

Please provide full details.

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Malaria

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?

C QIThis 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.

Malignant MelanomaC QI

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.

MigraineC QIThis condition refers to Question 7 of

the Medical History.

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.

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Miniscal Tears

Which knee is affected – or are both

affected?

Have you had surgery to the affected

knee(s). If so, what surgery have you had?

Do you have any current symptoms?

Do you have any treatment planned

or expected?

C QIThis 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.

Moles

Have you ever had mole mapping?

Have you ever had a benign mole or moles

removed? Please give details.

Have you ever been diagnosed with

dysplastic naevi syndrome?

C QIThis 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.

Non-Hodgkin's LymphomaC QIThis 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.

Osteoarthritis

Which joint or joints are affected?

Have you had any surgery? Please

provide full details.

If you have had surgery have you had metal

on metal hip replacement or hip

resurfacing?

C QIThis 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.

Osteoporosis

Have you suffered any fractured

bones?

If so, please provide full details.

C QIThis 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.

Otitis Media

Have you had any treatment or

symptoms in the last 2 years?

C QIThis condition refers to Question 11

of the Medical History.

If yes, please provide full details

including, treatment received and

dates.

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Peptic Ulcer Disease

Is the ulcer still present?

If not, when did you last experience

symptoms or have treatment?

C QIThis 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.

PsoriasisC QIThis condition refers to Question 6 of

the Medical History.

Ask the 4 standard questions on the Additional Information page of the Application Form.

Reflux Oesophagitis (without Hiatus Hernia)C QI

Is there a secondary condition

causing your reflux for example a

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.

Retinal DetachmentC QIThis condition refers to Question 11

of the Medical History.

Ask the 4 standard questions on the Additional Information page of the Application Form.

Rotator Cuff

Have you had surgery? If so, when?

Do you have any current symptoms?

C QIThis 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.

Rupture of kneesC QIThis condition refers to Question 8 of

the Medical History.

Ask the 4 standard questions on the Additional Information page of the Application Form.

Sebaceous Cyst

Do you currently have a sebaceous

cyst?

If you have had a sebaceous cyst in the

past, what treatment have you had?

C QIThis 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.

Squameous cell carcinoma

This condition refers to Question X of

the Medical History.

C QI

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.

C QI

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.

C QI

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?

C QI

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 CancerC QIThis condition refers to Question 5 of

the Medical History.

C QI

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.

C QI

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.

C QI

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)C QI

This condition refers to Question 6 of

the Medical History.

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.

C QI

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.

Hepatitis A

Are you currently undergoing

treatment, or have any

complications?

C QIThis 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.

Herpes Simplex

Do you currently have herpes

simplex, or do you have a history of

it?

Please provide details.

C QIThis 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.

Herpes Zoster / Shingles

Is this condition present or do you

have ongoing complications?

How many episodes have you had?

Have you fully recovered?

C QIThis 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.

Impaired Glucose Tolerance / pre DiabetesC QI

This condition refers to Question 2 of

the Medical History.

When was the condition diagnosed?

Do you take or have you taken any

medication either now or in the past?

Have you had any other treatment –

in the past? Do you have any

treatment planned or expected?

Ask the 4 standard questions on the Additional Information page of the

Application Form.

Now obtain the answers to the supplementary questions displayed here.

Kidney Cancer This condition refers to Question 5 of

the Medical History.

C QI

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.

C QI

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.

C QI

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.

C QI

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.

C QI

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.

C QI

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.

C QI

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.

C QI

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.