Name of Applicant	Nationality	N.I.E
Address	Town	Telephone
Date Birth	Email Address	Language
1) Do you suffer from any illness? Which? YES or NO
2) Have you been hospitalised for medical or surgical treatment? Indicate date and reason YES or NO
3) Are you being treated with any medincines, such as analgesics, traquillisers, diabetic or high blood pressure medication, antibiotics, anticoagulants for heart problems? Which? YES or NO
4) Do you consume alcohol, tobacco or drugs? YES or NO
5) Do you suffer from any after-effects from; Traffic accidents, accidental traumas or falls? YES orNO
6) Have you undergone rehabilitation, physiotherapy, or radioactive treatment? For what reason? YES or NO
7) Indicate if you suffer or have suffered from any of the following:
Respiratory System: Sinusitis, deviation of the nasal septum, aphonia, chronic bronchitis, lung tuberculosis, pneumonia, bronchial asthma or respitory allergies, pleurisy. Have you had a Broncho-scope?		Tick Here if Yes
Circulatory System: Cardiac insufficiency, carddiac arrhythmia, heart attack, angina pectoris, hypertension, pericarditis, syncope, congenital heart of valve disease such as mitral or aortic stenosis, stroke, pace maker, coronary by-pass, coronary graph (catheterism)?		Tick Here if Yes
Artery Illnesses: Intermittent Claudication or aotic aneurysm; Vien Illness; Varicous veins or phlebitis?		Tick Here if Yes
Digestive System; Oesophagus, stomach, duodenum or instine ulcers, colitis, diarrhoea chronic constipation, appendicitis, hiatus or groin hernias, hepatitis, jaundice, hepatic cirrhosis, billiary lithiasis (stones), blood in vomits or loss of blood in stools, haemorrhoids or anus fistulas, peritonitis, pancreatitis, inflamed intestine illness. Any other digestive illness?		Tick Here if Yes
Nervous System; Chronic headache, insomnia, convulsions o pralysis. Psychological illnesses: Depresions, neurosis, psycosis, alcoholism, drug addiction, meningitis, encephalitis or neuritis. Parkinson Disease, dimentia. Discal hernias. Any other illness?		Tick Here if Yes
Ear, Nose and Throat; Deafness, otitis, tonsilitis, adenoid vegetacions, vertigo, noise in ears?		Tick Here if Yes
EYE Disease; Myopia hyperopia, presbyopia, astgmatism, squint, catarcts, glaucoma (high tension in eyes), conjunctivitis, blindness, retina detachment. Have you undergone laser treatment?		Tick Here if Yes
Bones and Joints; Acute or chronic rheumatism, arthrosis or arthritis, dislocations and fractures, rickets and discalcification, lumbago, sciatica, gount, palsy, bone tumors, traumatological operations, arthroscope (menicus)?		Tick Here if Yes
Nephrology and Urology: Kidney illnesses such as nephritis, renal tuberculosis, colics caused by kidney stones, cysts in kidneys, prostate problems, bladder illnesses. Have you undergone lithotrity?		Tick Here if Yes
Skin Dease; Psoriasis, eczema, rashes, mycosis (fungus), skin allergies, skin and mucous tumors (lips and genitals)?		Tick Here if Yes
Endocrinology; Diabetes, goitre or thyroid illnesses or illnesses of other glands such as pituitary or suprarenal, obesity, acetona?		Tick Here if Yes
Infectious Diseases; Typhus, malta fever, meningitis, dysentery, leprosy, cholera, tuberculosis, syphilis, diphtheria, malaria?		Tick Here if Yes
Oncology; Tumors or cancers in any part of the body?		Tick Here if Yes
Haematology (Blood Diseases); Anaemia, haemorrhages, leukaemia, coagulation problems, hodgkin's disease, adenopathy (ganglion), rupture or removal of spleen, haemphilia?		Tick Here if Yes
Gynaecology and Obsterics; Difficult births, caesarian section, premature births, menstruation problems, miscarriages or provoked abortions, genital or breast tumors. Are you pregnant? Any other Female illnesses?		Tick Here if Yes
Other Diseases; Toxic syndrome, A.I.D.S, occupational diseases, intoxications?		Tick Here if Yes
8) If you have ticked Yes to any of the Above Please provide details?
9) Indicate if you suffer or have suffered any other illnesses which do not appear in this heath questionnaire?
10) Have you got National Heath Cover in Spain? YES or NO
I understand that this no obligations quote on ether me or the Medical Company that I’m requesting this quote from. That I have to the best of my knowledge and belief provided an accurate declaration of my current and past health to enable the Medical company to provide me an accurate quotation for Private Medical Insurance.
	Please Tick This Box To Indicate you read and agree to the above