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Cover for pre-existing conditions
Clinical Intelligence Questioning for Brokers & Distributors
to open the tool, click to the next page…
C QI
![Page 2: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/2.jpg)
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
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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.
![Page 4: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/4.jpg)
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)
![Page 5: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/5.jpg)
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: -
![Page 6: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/6.jpg)
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: -
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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
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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: -
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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: -
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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”.
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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.
![Page 12: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/12.jpg)
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.
![Page 13: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/13.jpg)
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.
![Page 14: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/14.jpg)
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.
![Page 15: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/15.jpg)
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.
![Page 16: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/16.jpg)
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.
![Page 17: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/17.jpg)
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.
![Page 18: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/18.jpg)
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.
![Page 19: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/19.jpg)
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.
![Page 20: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/20.jpg)
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:
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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.
![Page 22: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/22.jpg)
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.
![Page 23: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/23.jpg)
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.
![Page 24: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/24.jpg)
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.
![Page 25: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/25.jpg)
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.
![Page 26: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/26.jpg)
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.
![Page 27: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/27.jpg)
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.
![Page 28: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/28.jpg)
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.
![Page 29: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/29.jpg)
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.
![Page 30: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/30.jpg)
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.
![Page 31: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/31.jpg)
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.
![Page 32: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/32.jpg)
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.
![Page 33: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/33.jpg)
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.
![Page 34: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/34.jpg)
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.
![Page 35: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/35.jpg)
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.
![Page 36: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/36.jpg)
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.
![Page 37: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/37.jpg)
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.
![Page 38: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/38.jpg)
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.
![Page 39: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/39.jpg)
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.
![Page 40: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/40.jpg)
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.
![Page 41: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/41.jpg)
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.
![Page 42: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/42.jpg)
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.
![Page 43: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/43.jpg)
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.
![Page 44: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/44.jpg)
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.
![Page 45: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/45.jpg)
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.
![Page 46: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/46.jpg)
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.
![Page 47: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/47.jpg)
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.
![Page 48: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/48.jpg)
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.
![Page 49: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/49.jpg)
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.
![Page 50: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/50.jpg)
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.
![Page 51: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/51.jpg)
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.
![Page 52: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/52.jpg)
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.
![Page 53: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/53.jpg)
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.
![Page 54: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/54.jpg)
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.
![Page 55: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/55.jpg)
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.
![Page 56: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/56.jpg)
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.
![Page 57: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/57.jpg)
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.
![Page 58: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/58.jpg)
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.
![Page 59: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/59.jpg)
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.
![Page 60: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/60.jpg)
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.
![Page 61: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/61.jpg)
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.
![Page 62: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/62.jpg)
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.
![Page 63: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/63.jpg)
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.
![Page 64: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/64.jpg)
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.
![Page 65: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/65.jpg)
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.
![Page 66: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/66.jpg)
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.
![Page 67: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/67.jpg)
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.
![Page 68: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/68.jpg)
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.
![Page 69: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/69.jpg)
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.
![Page 70: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/70.jpg)
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.
![Page 71: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/71.jpg)
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.
![Page 72: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/72.jpg)
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.
![Page 73: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/73.jpg)
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.
![Page 74: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/74.jpg)
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.
![Page 75: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/75.jpg)
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.
![Page 76: Cover for pre-existing conditions Clinical Intelligence Questioning for Brokers & Distributors to open the tool, click to the next page… CQI](https://reader037.vdocuments.mx/reader037/viewer/2022110319/56649c7e5503460f949341d8/html5/thumbnails/76.jpg)
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.