Whole of Life Application Form (W10243) - Legal & General

FAMILY HISTORYClient one3No. ofrelativesaffectedYoungestageaffectedSecondyoungestage affectedClient two3No. ofrelativesaffectedYoungestageaffectedSecondyoungestage affectedHave any of your natural parents,brothers or sisters, before theage of 65, been diagnosed with ordied from any of the conditionslisted opposite?If ‘Yes’, please tick all that apply.If ‘No’, please tick ‘None ofthe above’.If ‘unknown’, please answerthe unknown question on thenext page.For each condition selected,please give:• the total number of relativeswho had the condition• the ages(s) at the time ofdiagnosis or death (exceptwhere indicated) – but only theyoungest (lowest) age(s).The conditions listed opposite arenot always hereditary and we donot intend to imply that they are.Heart attack, Angina, Stroke or Type 2 DiabetesCancer of the BreastCancer of the OvaryCancer of the Colon (Bowel)Cancer of another siteIf ‘Cancer of another site’, for each relative pleasetell us the part of the body affected by the ‘primary’cancer, that is, where it first occurred in the body.Heart attack, Angina, Stroke or Type 2 DiabetesCancer of the BreastCancer of the OvaryCancer of the Colon (Bowel)Cancer of another siteIf ‘Cancer of another site’, for each relative pleasetell us the part of the body affected by the ‘primary’cancer, that is, where it first occurred in the body.Cardiomyopathy (primary disorder of the heart muscle)Cardiomyopathy (primary disorder of the heart muscle)Multiple SclerosisMultiple SclerosisN/AN/AN/AN/AIf ‘Multiple Sclerosis’, please tell us the familymember(s) affected.If ‘Multiple Sclerosis’, please tell us the familymember(s) affected.MotherFatherMotherFatherBrother(s)Sister(s)Brother(s)Sister(s)Myotonic (Muscular) DystrophyMyotonic (Muscular) DystrophyPolyposis coli (Familial adenomatous)Polyposis coli (Familial adenomatous)Polycystic Kidney DiseasePolycystic Kidney DiseaseMotor Neurone DiseaseMotor Neurone DiseaseHuntington’s DiseaseHuntington’s DiseaseParkinson’s DiseaseParkinson’s DiseaseAlzheimer’s DiseaseAlzheimer’s DiseaseYou can ignore short or long sight;colour blindness; asthma; high bloodpressure; heart murmur (other thanin connection with cardiomyopathy);dermatitis: eczema; rheumatoid orosteo arthritis.Any OTHER disorder which runs in your familyfor which you are receiving regular follow up orscreening.If ‘Yes’, please give details of the disorder(s) andthe results of any investigations.Any OTHER disorder which runs in your familyfor which you are receiving regular follow up orscreening.If ‘Yes’, please give details of the disorder(s) andthe results of any investigations.None of the aboveNone of the aboveWhole of Life Protection Plan – Application Form and Additional Questionnaires Page 11