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

PART 2 – GENERAL HEALTH AND LIFESTYLE continuedClient oneClient twoHow often do you have a drinkcontaining alcohol?Tick only one answer.NeverMonthly or lessfrequentlySpecialoccasions onlyTwo or threetimes a monthNeverMonthly or lessfrequentlySpecialoccasions onlyTwo or threetimes a monthWeeklyWeeklyIf weekly, tell us on how manydays during a typical week youdrink alcohol.No. of days:If you answered 2/3 times a month or weekly,please tell us how much beer, strong beer, wine,spirits and other alcohol you drink on a typical daywhen you have alcohol:No. of days:If you answered 2/3 times a month or weekly,please tell us how much beer, strong beer, wine,spirits and other alcohol you drink on a typical daywhen you have alcohol:Type of drinkNo. of drinks:Type of drinkNo. of drinks:Normal strength beer, lager or ciderNormal strength beer, lager or ciderStrong beer, lager or cider. Alcohol byvolume (ABV) content of 6% or more.Glasses of wine, fortified wine or spiritsOther alcoholic drinks e.g. alcopopsStrong beer, lager or cider. Alcohol byvolume (ABV) content of 6% or more.Glasses of wine, fortified wine or spiritsOther alcoholic drinks e.g. alcopopsHave you ever been medicallyadvised to reduce your alcoholconsumption or been referredfor specialist help to deal withalcohol consumption such as toan alcohol addiction unit or toAlcoholics Anonymous?Please ignore advice to reducealcohol given due to pregnancy.Tick all that apply.Yes – advised to reduce alcoholconsumptionYes – referred for specialist helpNoIf you answered ‘Yes’ to the previous question,please tell us:Who advised you to reduce your alcoholconsumption and when was this?Yes – advised to reduce alcoholconsumptionYes – referred for specialist helpNoIf you answered ‘Yes’ to the previous question,please tell us:Who advised you to reduce your alcoholconsumption and when was this?What was the reason for this advice?What was the reason for this advice?What was your alcohol intake at the time?What was your alcohol intake at the time?YOUR HEALTHWhen answering the following questions, if you are unsure of the relevance of any medical condition you have had, please let us know anyway.Where examples are shown, they are not intended to be a complete list. However there is no need to state the same medical condition morethan once when answering the questions.Client oneClient two1. Have you ever had:a) diabetes or a heart condition, for exampleangina, heart attack, heart valve problem orheart surgery?YesNoYesNob) Please ignore varicose veins,unless there is ulceration present.b) a stroke, mini stroke, transient ischaemicattack (TIA), brain haemorrhage or surgery toyour blood vessels?YesNoYesNod) Please ignore long andshort sightedness that havebeen corrected.c) any form of cancer, Hodgkin lymphoma,Non-Hodgkin lymphoma, leukaemia, skincancer, melanoma or a tumour, cyst orbenign growth in the brain or spine?d) multiple sclerosis, epilepsy, fits or visiondisturbances, for example optic orretrobulbar neuritis?YesYesNoNoYesYesNoNoe) muscular dystrophy, cerebral palsy, permanentbrain injury or any neurological condition, forexample motor neurone disease or Parkinson’sdisease?YesNoYesNof) any mental illness, anorexia or bulimia thathas required hospital treatment or referral toa psychiatrist?YesNoYesNoIf you have answered ‘Yes’ to ANY part of the above question, please complete one of the Medical Questionnaires (Part 6) BEFOREcontinuing with the next question.Whole of Life Protection Plan – Application Form and Additional Questionnaires Page 9