Risk Management Client Client What is your job title? Are you degree qualified? Yes No Yes No What is your highest qualification? Describe your day to day duties including a description of what manual work you complete Manual work as a % of – Do you intend to change employment in the near future? If Yes__________________ No Yes__________________ No yes, when? If yes, what will be your new occupation? Current weight/height kg cm kg Cm Excellent Good Excellent Good Health status: Average Poor Average Poor Do you have any health issues or currently receiving medical advice? If yes, please provide details What regular medication do you take (if any)? Have you smoked in the last Yes No Yes No 12 months? Do you rely on paid employment to Yes No Yes No your expenses? Upon whose income are you/your You solely family dependent on to maintain You solely your lifestyle needs? e.g. To cover Your partner solely Your partner solely the mortgage and day-to-day living Both Both expenses How would your family’s lifestyle needs be maintained if you or your partner were temporarily unable to earn an income? For example, through sickness/illness? Temporary Illness In the event of prolonged or serious illness or accident, where _______% _______% between 0% and 100% would you ideally want your income to be replaced? Yes Would you want to provide a provision for medical costs and No Yes No care? Would you value access to a patient advocacy / second Yes No Yes No opinion medical service?
Risk Management Client Client What is your job title? Are you degree qualified? Yes No Yes No What is your highest qualification? Describe your day to day duties including a description of what manual work you complete Manual work – as a % of Do you intend to change employment in the near future? If yes, when? Yes__________________ No Yes__________________ No If yes, what will be your new occupation? Current weight/height kg cm kg Cm Health status: Excellent Average Good Poor Excellent Average Good Poor Do you have any health issues or currently receiving medical advice? If yes, please provide details What regular medication do you take (if any)? Have you smoked in the last 12 months? Yes No Yes No Do you rely on paid employment to your expenses? Yes No Yes No Upon whose income are you/your family dependent on to maintain your lifestyle needs? e.g. To cover the mortgage and day-to-day living expenses You solely Your partner solely Both You solely Your partner solely Both How would your family’s lifestyle needs be maintained if you or your partner were temporarily unable to earn an income? For example, through sickness/illness? Temporary Illness In the event of prolonged or serious illness or accident, where between 0% and 100% would you ideally want your income to be replaced? _______% _______% Would you want to provide a provision for medical costs and care? Yes No Yes No Would you value access to a patient advocacy / second opinion medical service? Yes No Yes No