Step 1 of 9 11% Hi There! You ready? Let's start You might need to upload digital copies of the following documents where applicable. 1. Identity Documents / Passports / Birth Certificates 2. Membership certificate(s) from previous medical scheme(s) 3. Proof of registration at educational institution / affidavit confirming financial dependency for adult dependants 21 years and older 4. Proof of adopted or foster children 5. Marriage Certificate / Marriage Affidavit Certificate What would you like to do?* Get a quote and apply online I would like a sales consultant to call me What do you need?* Comprehensive Cover Family plan with traditional day to day benefits Hospital plan with a discretionary savings account for day to day benefits Hospital plan only Comprehensive Cover[showlayout id=235685]Family Plan[showlayout id=235675]Hospital & Savings Plan[showlayout id=235624]Hospital Plan[showlayout id=235387]Pick Your PlanWhich Comprehensive Option Would You Like to Apply For?*SelectPinnaclePinnacle Efficiency DiscountDynamixDynamix Efficiency DiscountWhich Family Plan / Traditional Option Would You Like to Apply For?*SelectSymmetrySymmetry Efficiency DiscountMumedMumed Efficiency DiscountWhich Hospital & Savings Option Would You Like to Apply For?*SelectUnisaveWhat Hospital Option Would You Like to Apply For?*SelectMedxMedx Efficiency DiscountNext StepsWhen Should Your Medical Aid Start?1 January1 February1 March1 April1 May1 June1 July1 August1 September1 October1 November1 December20212022What would you like to do?* I would like to apply online for the plan that I selected. I would like a sales consultant to give me a call Name* First Last Title*SelectMr.Mrs.MissDr.Ms.Prof.Initials* Marital StatusPlease Select Your StatusSingleDivorcedMarriedWidowedCommon LawTribal LawSeparatedEmail* Mobile Number* South African ID Number Passport Number South African ID Number Passport Number Birthdate DD slash MM slash YYYY Present Age Gender*SelectMaleFemaleRace*BlackColouredWhiteIndianAsianOtherTax Number HiddenWhen would you want to join? MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country My postal address is the same as my physical address My postal address is the same as my physical address Postal Code* Box Number City Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Would you like to add dependants?*NoYesChoose the number of dependants*Select12345Dependent 1Title*Mr.Mrs.MissDr.Ms.Prof.Relationship to Member*ChooseSpouse/PartnerChild (Adopted Child)ParentName* First Last Initial* Email* Mobile Number* ID Number* Birthdate MM slash DD slash YYYY Gender*MaleFemaleEnd Dependent 1Dependent 2Title*Mr.Mrs.MissDr.Ms.Prof.Relationship to Member*ChooseSpouse/PartnerChild (Adopted Child)ParentName* First Last Initial* Email* Mobile Number* ID Number* Birthdate MM slash DD slash YYYY Gender*MaleFemaleEnd Dependent 2Dependent 3Title*Mr.Mrs.MissDr.Ms.Prof.Relationship to Member*ChooseSpouse/PartnerChild (Adopted Child)ParentName* First Last Initial* Email* Mobile Number* ID Number* Birthdate MM slash DD slash YYYY Gender*MaleFemaleEnd Dependent 3Dependent 4Title*Mr.Mrs.MissDr.Ms.Prof.Relationship to Member*ChooseSpouse/PartnerChild (Adopted Child)ParentName* First Last Initial* Email* Mobile Number* ID Number* Birthdate MM slash DD slash YYYY Gender*MaleFemaleEnd Dependent 4Dependent 5Title*Mr.Mrs.MissDr.Ms.Prof.Relationship to Member*ChooseSpouse/PartnerChild (Adopted Child)ParentName* First Last Initial* Email* Mobile Number* ID Number* Birthdate MM slash DD slash YYYY Gender*MaleFemaleEnd Dependent 5 Born After 1985 - YesShow if born after than 1985 and yesYour Medical History It is most important that the questions on the following page be answered as thoroughly as possible. The answers to these questions will be treated as confidential. It is important to note that any medical condition, of which you are aware, not disclosed in this application, can be excluded from benefit. Please advise whether you or any of your dependants suffer from, or have suffered from, or received treatment/consultation for any of the following conditions. Please ensure that you tick and complete the appropriate block/s.Heart & Vascular System*High blood pressure; high cholesterol; angina; heart attack; angiogram; previous coronary artery bypass; rheumatic fever; heart murmurs; valve problems / replacement; arrhythmias – insertion of pacemakers; heart failure; stroke; varicose veins; DVTs (deep vein thrombosis); pulmonary embolism.NoYesChoose dependents with Heart & Vascular System problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakEmotional (psychological, psychosomatic problems)*Depression; bipolar disorder; anxiety; stress; previous treatment for post traumatic stress syndrome; eating disorders – bulimia & anorexia; mental retardation; alcoholism; drug abuse. Have you or any of your dependants been on sleeping tablets or antidepressants?NoYesChoose dependents with emotional (psychological, psychosomatic problems) problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakGynaecological System*Menopause; female hormone replacement; irregular menses; infertility; breast tumours (benign / malignant); ovarian tumours; cysts; prolapsed uterus / rectum / bladder; miscarriage; caesarean section; etc.NoYesChoose dependents with Gynaecological System problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakBone; Muscle & Joints*Arthritis; rheumatism; gout; back, knee or neck problems; fibromyalgia; previous fractures; deformities; degenerative muscle disease; osteoporosis; etc.NoYesChoose dependents with Bone; Muscle & Joints problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakNervous System*Persistent headaches; epilepsy; paralysis; degenerative diseases – Alzheimer’s; Parkinson’s; multiple sclerosis; stroke; neuralgias; ADD (attention deficit disorder).NoYesChoose dependents with Nervous System problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakGland / Hormonal*Over / under active thyroid; diabetes mellitus; Cushing’s syndrome; Addison’s disease; pituitary gland abnormality.NoYesChoose dependents with Gland / Hormonal problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakMale Genital System*Prostate problems (hypertrophy / cancer or infections); infertility; hernias – groin; scrotal swellings; testicular tumours; abnormalities of the penis; problems with urination.NoYesChoose dependents with Male Genital System problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakEar, Nose & Throat*Allergies (rhinitis, sinusitis); chronic infections (otitis, tonsillitis); nasal reconstruction; snoring; sleep apnoea; deafness – hearing aids.NoYesChoose dependents with Ear, Nose & Throat problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakEyes*Poor vision; birth defects; degenerative disease (glaucoma; retinitis pigmentosa; cataracts; keratoconus); allergies – pterygiums; anticipated / previous laser surgery; artificial eyes.NoYesChoose dependents with Eye problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakPregnancy*Are you or any of your dependants pregnant? If yes - how many weeks? Please give expected date of delivery.NoYesChoose dependents with Pregnancy problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakLungs*Asthma; emphysema; chronic bronchitis; TB; chronic infections - bronchitis & pneumonia.NoYesChoose dependents with Lung problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakUrinary Tract*Infections; stones; albumin / blood in urine; urinary incontinence; prolapsed bladder.NoYesChoose dependents with Urinary Tract problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakBlood*Anaemia; bleeding disorders (haemophilia); leukaemia; Hodgkin’s disease.NoYesChoose dependents with Blood problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakDigestive System, Gallbladder; Liver*Dyspeptic disease (heartburn; hiatus hernia; peptic ulcers; reflux); irritable bowel syndrome (spastic colon; inflammatory bowel disease e.g. Crohn's & ulcerative colitis; chronic diarrhoea / constipation); gallstones & jaundice; hepatitis; pancreatitis; haemorrhoids; incontinence; bowel prolapse.NoYesChoose dependents with Digestive System, Gallbladder; Liver problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakImmuno-Suppressive Treatment*Have you or any of your dependants ever had or expecting to undergo an organ treatment transplant? Have you or any of your dependants ever suffered from any condition requiring Immunosuppressive treatment?NoYesChoose dependents with Immuno-Suppressive Treatment problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakChronic Conditions*Do you or any of your dependants have a chronic condition requiring ongoing medication? If yes, please give the name and dosage of all the medication you or any of your dependants are currently taking.NoYesChoose dependents with Chronic Conditions problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakMedical Treatment*Are you or any of your dependants expecting to undergo any medical treatment, e.g. hospitalisation, operation, specialised dentistry etc, within the next twelve months?NoYesChoose dependents with Medical Treatment below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakMedical Attention*Have you or any of your dependants ever received any medical attention of any nature, e.g., hospitalisation, operation, specialised dentistry etc, not mentioned above?NoYesChoose dependents with Medical Attention below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakInfections / Tropical Diseases*Sexually transmitted diseases; genital warts; HIV / AIDS; hepatitis; ME-Virus (Yuppie Flu); malaria; bilharzias; cholera; typhoid.NoYesChoose dependents with Infections / Tropical Diseases problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSkin Disorders*Acne; eczema; psoriasis; lesions (keloid hypertrophic scars); skin rashes; shingles; Kaposi sarcoma – tumours.NoYesChoose dependents with Skin Disorders problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakAllergies*Are you or any of your dependants allergic to any specific type of medication (e.g. penicillin, aspirin, sulphas, morphine, NSAIDS); pollen dust; animals; specific food types (e.g. nuts).NoYesChoose dependents with Allergies problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakTeeth & Gums*Impacted molars (wisdoms); previous / current orthodontic treatment; braces; crowns; recurrent infections - gums.NoYesChoose dependents with Teeth & Gum problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakTherapy/Treatments*Have you or any of your dependants ever received any form of physiotherapy, occupational therapy or chiropractic treatment?NoYesChoose dependents with Therapy/Treatments problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakConnective Tissue Disorders*Systemic lupus erythromatosis; scleroderma; rheumatoid arthritis.NoYesChoose dependents with Connective Tissue Disorders problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakCancer*Cysts; growths; tumours of any kind.NoYesChoose dependents with Cancer problems below Heart & Vascular System 1 Heart & Vascular System 2 Heart & Vascular System 3 Heart & Vascular System 4 Heart & Vascular System 5 Heart & Vascular System 6 Section BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact NumberSection BreakSection BreakDiagnosis Treating Doctor Date Diagnosed MM slash DD slash YYYY Date Duration Period MM slash DD slash YYYY Practice Number Contact Number
