Personal Health and Activities Form

Date of Birth*

DD

MM

YYYY

Age

Full name

Occupation & Duties

(e.g. 80% computer work, 10% driving, 10% admin)

Have you smoked, vaped or used and E-cigarette in the last 12m?

Yes
No

Height

Weight

Have you ever been to hospital for an operation or treatment?

Yes
No

If yes - explain briefly

Are you on any regular medication, receiving advice or monitoring for a medical condition?

Yes
No

If yes - explain briefly

Have you ever suffered symptoms of or been diagnosed with problems in the following areas?

Cancer or tumour

Yes
No

Knees, hips or back

Yes
No

Arthritis

Yes
No

Heart or arteries / cholesterol

Yes
No

High blood pressure

Yes
No

Diabetes

Yes
No

Anxiety, depression or mental disorders

Yes
No

Asthma or lung disorder

Yes
No

Drug or alcohol dependency

Yes
No

Kidney/Liver disease or disorders

Yes
No

Sleep problems

Yes
No

Blood disorders incl. HIV/AIDS

Yes
No

Chronic fatigue or pain

Yes
No

Other illness or condition not stated

Yes
No

In the last 5 years have you dealt with ACC over an injury?

Yes
No

Parents or siblings suffered from serious illness/condition

Yes
No

(e.g. heart attack, cancer etc)

If yes – explain briefly

Do you participate in any hazardous activities e.g. Scuba diving, motor sport, parachuting, rock gliding, mountain climbing, caving, hang gliding etc? Hunting – Aerial/non-aerial

Yes
No

If yes – provide details

Mortgages

Resources

Insurance

DEBT

Resources

Personal Health and Activities Information

Have you ever suffered symptoms of or been diagnosed with problems in the following areas?

Have you ever suffered symptoms of or been diagnosed with problems in the following areas?

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