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  • General surgery
  • Non-surgical cancer treatment
  • Major diagnostic procedures
  • Non-PHARMAC subsidised drugs
  • Options for having treatment overseas
  • Cover while in Australia
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  • General surgery
  • Non-surgical cancer treatment
  • Major diagnostic procedures
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  • General surgery up to $500,000 per year
  • Major diagnostic procedures
  • Pay for no more than two children on your policy
  • Free for babies up to six months of age
  • Loyalty benefit of $150 towards exercise activity
  • Loyalty benefit for release of tongue / lip tie
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  • General surgery
  • Oral surgery
  • Major diagnostic procedures
  • Treatment outside New Zealand
  • Air transport and accommodation benefit
  • Physiotherapy
  • Home nursing
  • Free cover for first child
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  • General surgery
  • Oral surgery
  • Major diagnostic procedures
  • Treatment outside New Zealand

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Benefits Download info

  • Specialist consultations
  • Minor diagnostic tests

Natural Health plan

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  • Chiropractic consultations
  • Osteopath consultations
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  • Other health practitioner consultations

GP plan

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  • Doctor and nurse visits
  • Prescriptions
  • Laboratory tests

Dental and Optical plan

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  • Dental treatments
  • Optical cover

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Medical records

Brandon Stewart


Delete and complete a health questionnaire

Preliminary questions


*Have youHas your child

  1. ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for any other illness, accident, injury, condition, complaint, disability, medication or disorder not already stated in your GP medical notes?
  2. been hospitalised or had any tests, medical treatment or investigations in the last five years or be intending to for any condition not already stated, including, but not limited to blood and/or urine test, X-ray, ultrasound, CT scan, mammogram, MRI, gastroscopy, colonoscopy, endoscopy, hysteroscopy or laparoscopy?
  3. had more than five consecutive days off work or school in the past five years due to any condition not already stated?

*Have youHas your child ever had oral surgery or experienced, had symptoms of, been treated for or been advised to seek testing or treatment for wisdom teeth, impacted or unerupted teeth, cysts or gum disease?


*Have any of your child's parents, brothers, sisters (living or dead) had or been diagnosed with any of the following: cancer, stroke, heart disease, diabetes, kidney disease, Huntington's chorea, muscular dystrophy, cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological or blood disease or any familial and/or congenital disease or disorder?

*Have any of your parents, brothers, sisters or children (living or dead) had or been diagnosed with any of the following: cancer, stroke, heart disease, diabetes, kidney disease, Huntington's chorea, muscular dystrophy, cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological or blood disease or any familial and/or congenital disease or disorder?


Health questionnaire

Brandon Stewart


Delete health questionnaire

Preliminary questions


Please indicate below if you have experienced or are currently experiencing or had symptoms of or are currently experiencing symptoms of or been treated for or are currently being treated for or been advised to seek testing, therapy, consultation or treatment for any of the following.

If you answer YES to any question below, you will be asked to complete further information about the condition.

Please note that these definitions apply wherever mentioned:

  1. Recurrent - more than once in any 12-month period.
  2. Recent - within the past 12 months.


Heart

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for angina/chest pain, heart attack, heart failure, abnormal heart beat, arrhythmia, heart murmur or rheumatic fever?


Raised blood pressure; raised or abnormal cholesterol

Have you ever experienced had symptoms of, been treated for or been advised to seek testing or treatment for raised blood pressure or raised or abnormal cholesterol?


Breathing or respiratory disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for shortness of breath, asthma, COPD, chest infections, pneumonia, bronchitis, tuberculosis, emphysema or sleep disorders?


Digestive disorders; stomach, intestine, liver or gall bladder problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for gastritis, ulcers, reflux, irritable bowel, Crohn's disease, colitis, coeliac disease, bowel polyps, abdominal pain, pancreatitis, liver inflammation, fatty liver, cirrhosis, gallstones or hernias?


Cancer, cysts, tumours or growths

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for polyps, benign growths, any cancers or pre-cancerous condition, suspicious moles, cysts, abscesses, ganglions, basal cell carcinoma or melanoma?


Muscle or skeletal problems (including cartilage, tendon and ligament problems)

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for arthritis, back pain, neck/shoulder problems, whiplash, sciatica, scoliosis, ankylosing spondylitis, OOS, RSI, carpal tunnel, joint replacements, fractures, osteoporosis, gout or inflammatory conditions or any disorders of the hips, knees, ankles, feet, toes, shoulders, arms, elbows, wrists, hands or fingers?


Blood, immune or circulatory disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for abnormal blood tests, anaemia, hepatitis, HIV, haemochromatosis, vitamin B12 deficiency, haemophilia, lupus or any autoimmune disorder; varicose veins, DVT or blood clots?


Endocrine (glandular) disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for diabetes (Type 1 or Type 2), thyroid problems, Graves' disease, abnormal thyroid function tests, pituitary problems or abnormal blood sugar and/or glucose tolerance tests?


Urinary or kidney disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for kidney or bladder problems, incontinence, urinary difficulties, kidney stones or kidney infections, kidney failure or recent and/or recurrent UTIs?


Anal/rectal problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for haemorrhoids, change in bowel habit, anal fissures, anal bleeding or pilonidal sinus?


Skin problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for eczema, dermatitis, rashes, psoriasis, acne or allergic conditions?


Brain or nervous system disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for stroke, TIA, aneurysms, migraine, repeated headaches, vertigo, fainting, dizziness, multiple sclerosis, epilepsy/seizures, paralysis, motor neuron disease, nerve pain or meningitis?


Fatigue or pain syndromes

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for chronic fatigue, fibromyalgia or chronic pain syndrome?


Eye, ear and throat problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for cataracts, glaucoma, visual impairment, hearing loss, tinnitus, recent and/or recurrent ear infections, grommets, enlargement of adenoids, tonsillitis or recent and/or recurrent throat infections?


Allergies, nasal and/or sinus problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for anaphylaxis, nasal obstruction, hay fever, sinusitis or recent and/or recurrent sinus infections?


Dental problems

Have you ever had oral surgery or experienced, had symptoms of, been treated for or been advised to seek testing or treatment for wisdom teeth, impacted or unerupted teeth, cysts or gum disease?


To be completed by males only

Have you ever experienced any signs or symptoms of, or are you currently receiving or have you ever received counselling, investigations or treatment from a health professional for, any of the following: blood in the urine, slow urinary stream, problems with passing urine, disease or disorder of the testicles, bladder, urethra or prostate, sexual dysfunction or abnormal prostate tests?


To be completed by females only

Have you ever experienced any signs or symptoms of, or are you currently receiving or have you ever received counselling, investigations or treatment from a health professional for, any of the following: breast disease or disorder, breast lumps, cysts or breast pain, gynaecological disorder of any kind, endometriosis, polycystic ovarian syndrome, irregular, heavy or painful menstrual bleeding, ovarian or hormonal problems, complications of pregnancy, abnormal smear(s), painful intercourse and/or prolapse?


Other conditions

Have you

  • Ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for any other illness, accident, injury, condition, complaint, disability, medication or disorder not already stated?
  • Been hospitalised or had any tests, medical treatment or investigations in the last five years or be intending to for any condition not already stated, including, but not limited to blood and/or urine test, X-ray, ultrasound, CT scan, mammogram, MRI, gastroscopy, colonoscopy, endoscopy, hysteroscopy and laparoscopy?
  • Had more than five consecutive days off work or school in the past five years due to any condition not already stated?

Family history

Have any of the dependants parents, brothers or sisters (living or dead) had or been diagnosed with any of the following: cancer, stroke, heart disease, diabetes, kidney disease, Huntington's chorea, muscular dystrophy, cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological or blood disease or any familial and/or congenital disease or disorder?

Have any of your parents, brothers, sisters or children (living or dead) had or been diagnosed with any of the following: cancer, stroke, heart disease, diabetes, kidney disease, Huntington's chorea, muscular dystrophy, cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological or blood disease or any familial and/or congenital disease or disorder?


Health questionnaire

Brandon Stewart


Delete health questionnaire

Heart

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for angina/chest pain, heart attack, heart failure, abnormal heart beat, arrhythmia, heart murmur or rheumatic fever?

*Required fields


*Please provide details of the cardiac disorder

Provide details


*When did you first experience symptoms of this condition?


*When did you last experience symptoms of this condition?


*Have you been referred to or consulted a GP or specialist about symptoms of any of the above?

If yes, please provide details


*Have you ever undergone or been advised to undergo any investigations and/or treatment for this condition?

If yes, please provide details


*Have you experienced any residual effects?

If yes, please provide details


*Do you require any ongoing treatment, medication and/or monitoring?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Raised blood pressure; raised or abnormal cholesterol

Have you ever experienced had symptoms of, been treated for or been advised to seek testing or treatment for raised blood pressure or raised or abnormal cholesterol?

*Required fields


*Do you suffer or have you been advised by a medical practitioner that you suffer from:


*When did you first become aware you had raised blood pressure?


*When did you first become aware you had abnormal cholesterol?


*What treatment and/or medication have you been prescribed?

Provide details


Has your treatment changed in the last 12 months?

If yes, please provide details


*How often is your blood pressure and/or cholesterol checked and by whom?

Provide details


What were your three most recent blood pressure readings and cholesterol results?

Blood pressure

Cholesterol


*Have you ever been admitted to hospital or consulted a specialist or been referred to a specialist as a result of your blood pressure and/or cholesterol readings?

If yes, please provide details


Do you suffer from any complications or associated conditions?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Breathing or respiratory disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for shortness of breath, asthma, COPD, chest infections, pneumonia, bronchitis, tuberculosis, emphysema or sleep disorders?

*Required fields


*Please provide details of the breathing disorder (e.g. asthma, bronchitis)

Provide details


*When did you first experience symptoms of this condition?


*When did you last experience symptoms of this condition?


*What treatment and/or medication have you been prescribed?

Provide details


*How frequent are/were the symptoms?

OR


*How severe do you consider your breathing disorder to be?


Have you been hospitalised and/or been on a nebuliser in the last two years?

If yes, please provide details


Have you been prescribed steroids (e.g. prednisone) in the last two years?

If yes, please provide details


Have you been referred to a specialist for investigations and/or treatment?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Digestive disorders; stomach, intestine, liver or gall bladder problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for gastritis, ulcers, reflux, irritable bowel, Crohn's disease, colitis, coeliac disease, bowel polyps, abdominal pain, pancreatitis, liver inflammation, fatty liver, cirrhosis, gallstones or hernias?

*Required fields


*Please provide details of the type of digestive disorders and/or stomach, intestine, liver or gall bladder problems

Provide details


*When did you first experience symptoms of this condition?


*Do you still experience symptoms of this condition?

If no, when did you last experience symptoms?

If yes, how many times per year?


*Have you been referred to or consulted a GP or specialist about symptoms of any of the above?

If yes, please provide details


*Have you ever undergone or been advised to undergo any investigations of the gastrointestinal tract (e.g. gastroscopy, endoscopy, colonoscopy)?

If yes, please provide details


*Have you undergone or been advised to undergo any treatment for this condition (including surgery)?

If yes, please provide details


*Have you in the past or are you currently taking any medication for this condition?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Cancer, cysts, tumours or growths

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for polyps, benign growths, any cancers or pre-cancerous condition, suspicious moles, cysts, abscesses, ganglions, basal cell carcinoma or melanoma?

*Required fields


*Please provide details


*Which body part or organ is affected by this condition?

Provide details


*When did you first experience symptoms of this condition?


*What treatment was undertaken or advised? If surgical removal, please provide date.


If no treatment was undertaken, is the condition still present?


* Do you know if the condition was:


Has there been any recurrence?

If yes, please provide details


* Have you seen a specialist, do you require any ongoing follow-up, treatment or monitoring or has any follow-up/further treatment been recommended?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Muscle or skeletal problems (including cartilage, tendon and ligament problems)

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for arthritis, back pain, neck/shoulder problems, whiplash, sciatica, scoliosis, ankylosing spondylitis, OOS, RSI, carpal tunnel, joint replacements, fractures, osteoporosis, gout or inflammatory conditions or any disorders of the hips, knees, ankles, feet, toes, shoulders, arms, elbows, wrists, hands or fingers?

*Required fields


*What is the name of the condition/complaint/injury?

Provide details:


*What body part is affected? Please indicate if left or right limb

Provide details:


*When did you first suffer from this condition/complaint/injury, and how did it occur?


*How long did the symptoms last?

Provide details


*When did you last suffer from symptoms?


Has this condition occurred more than once?

If yes, please provide details


*Have you been referred to or consulted a GP or specialist about symptoms of any of the above?

If yes, please provide details


*Have you had any investigations?

If yes, please provide details


*Have you had any treatment (including surgery)?

If yes, please provide details


Have you had any time off work / school as a result of this condition?

If yes, please provide start date

and duration of this time


Have you made a claim to ACC in respect of this condition?

If yes, please provide details


*Are you currently receiving treatment?

If yes, please provide details


*Are you awaiting investigations, treatment or surgery, or have you been advised that treatment or surgery will be required?

If yes, please provide details


*Have you experienced any pain or discomfort since the last episode/symptoms?

If yes, please provide details


*Are you aware of any arthritis or degeneration in the affected body part(s)?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Blood, immune or circulatory disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for abnormal blood tests, anaemia, hepatitis, HIV, haemochromatosis, vitamin B12 deficiency, haemophilia, lupus or any autoimmune disorder; varicose veins, DVT or blood clots?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*When did you last experience symptoms?


How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Endocrine (glandular) disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for diabetes (Type 1 or Type 2), thyroid problems, Graves' disease, abnormal thyroid function tests, pituitary problems or abnormal blood sugar and/or glucose tolerance tests?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*When did you last experience symptoms?


How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Urinary or kidney disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for kidney or bladder problems, incontinence, urinary difficulties, kidney stones or kidney infections, kidney failure or recent and/or recurrent UTIs?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Anal/rectal problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for haemorrhoids, change in bowel habit, anal fissures, anal bleeding or pilonidal sinus?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Skin problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for eczema, dermatitis, rashes, psoriasis, acne or allergic conditions?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Brain or nervous system disorders

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for stroke, TIA, aneurysms, migraine, repeated headaches, vertigo, fainting, dizziness, multiple sclerosis, epilepsy/seizures, paralysis, motor neuron disease, nerve pain or meningitis?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Fatigue or pain syndromes

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for chronic fatigue, fibromyalgia or chronic pain syndrome?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Eye, ear and throat problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for cataracts, glaucoma, visual impairment, hearing loss, tinnitus, recent and/or recurrent ear infections, grommets, enlargement of adenoids, tonsillitis or recent and/or recurrent throat infections?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Allergies, nasal and/or sinus problems

Have you ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for anaphylaxis, nasal obstruction, hay fever, sinusitis or recent and/or recurrent sinus infections?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Dental problems

Have you ever had oral surgery or experienced, had symptoms of, been treated for or been advised to seek testing or treatment for wisdom teeth, impacted or unerupted teeth, cysts or gum disease?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*When did you last experience symptoms?


How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

To be completed by males only

Have you ever experienced any signs or symptoms of, or are you currently receiving or have you ever received counselling, investigations or treatment from a health professional for, any of the following: blood in the urine, slow urinary stream, problems with passing urine, disease or disorder of the testicles, bladder, urethra or prostate, sexual dysfunction or abnormal prostate tests?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

To be completed by females only

Have you ever experienced any signs or symptoms of, or are you currently receiving or have you ever received counselling, investigations or treatment from a health professional for, any of the following: breast disease or disorder, breast lumps, cysts or breast pain, gynaecological disorder of any kind, endometriosis, polycystic ovarian syndrome, irregular, heavy or painful menstrual bleeding, ovarian or hormonal problems, complications of pregnancy, abnormal smear(s), painful intercourse and/or prolapse?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Other conditions

Have you

  • Ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for any other illness, accident, injury, condition, complaint, disability, medication or disorder not already stated?
  • Been hospitalised or had any tests, medical treatment or investigations in the last five years or be intending to for any condition not already stated, including, but not limited to blood and/or urine test, X-ray, ultrasound, CT scan, mammogram, MRI, gastroscopy, colonoscopy, endoscopy, hysteroscopy and laparoscopy?
  • Had more than five consecutive days off work or school in the past five years due to any condition not already stated?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


*How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Health questionnaire

Brandon Stewart


Delete health questionnaire

Family history

Have any of the dependants parents, brothers or sisters (living or dead) had or been diagnosed with any of the following: cancer, stroke, heart disease, diabetes, kidney disease, Huntington's chorea, muscular dystrophy, cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological or blood disease or any familial and/or congenital disease or disorder?

Have any of your parents, brothers, sisters or children (living or dead) had or been diagnosed with any of the following: cancer, stroke, heart disease, diabetes, kidney disease, Huntington's chorea, muscular dystrophy, cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological or blood disease or any familial and/or congenital disease or disorder?

*Required fields


*Medical condition (If cancer, specify type and site)

Provide details


*Family member affected

Provide details


*Age at diagnosis

Provide details


*Current age

*Or age at death


Payment details

Payment



Direct debit


OR

Details for my bank statement:


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Please read the conditions of this authority to accept direct debits.

Read direct debit terms & conditions


Policy summary

$0/mth

(incl. 3% direct debit discount)
Base plan
members covered
$0/mth
($0 excess)

Medical records

Brandon Stewart


Delete and complete a health questionnaire

Other conditions

Have you

  1. ever experienced, had symptoms of, been treated for or been advised to seek testing or treatment for any other illness, accident, injury, condition, complaint, disability, medication or disorder not already stated in your GP medical notes?
  2. been hospitalised or had any tests, medical treatment or investigations in the last five years or be intending to for any condition not already stated, including, but not limited to blood and/or urine test, X-ray, ultrasound, CT scan, mammogram, MRI, gastroscopy, colonoscopy, endoscopy, hysteroscopy or laparoscopy?

*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*Please describe the symptoms

Provide details


*When did you last experience symptoms?


How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Medical records

Brandon Stewart


Delete and complete a health questionnaire

Dental problems

Have you, or any of the lives to be insured ever had oral surgery or experienced, had symptoms of, been treated for or been advised to seek testing or treatment for wisdom teeth, impacted or unerupted teeth, cysts or gum disease?

*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*When did you last experience symptoms?


How frequent and severe are/were the occurrences or attacks of the condition?

How frequent?

OR

How severe?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Medical records


Delete and complete a health questionnaire

Family history

Have any of the dependants parents, brothers or sisters (living or dead) had or been diagnosed with any of the following: cancer, stroke, heart disease, diabetes, kidney disease, Huntington's chorea, muscular dystrophy, cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological or blood disease or any familial and/or congenital disease or disorder?

Have any of your parents, brothers, sisters or children (living or dead) had or been diagnosed with any of the following: cancer, stroke, heart disease, diabetes, kidney disease, Huntington's chorea, muscular dystrophy, cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological or blood disease or any familial and/or congenital disease or disorder?

*Medical condition (If cancer, specify type and site).

Provide details


*Family member affected

Provide details


*Age(s) at diagnosis

Provide details


*Current age

*Or age at death


Medical records


Delete and complete a health questionnaire

Upload medical documents

We understand that it can be hard for you to remember all the details of your health conditions, and as such, we are happy to underwrite based on your child's full medical notes (from birth). You can ask your GP for an electronic copy of this for little or no charge. To help you, we have prepared the text you could include in an email or use as a script when calling them to make your request.

Example email

Note: Your GP may provide a patient portal. If so, your child's medical records may already be available to you once you have registered to use the portal. For more information about access to your medical notes please see Health information Check-up: Know Your Privacy Rights, produced by the Privacy Commissioner.

You can upload your medical records from your computer in .jpeg, .tif, .png and .pdf file formats.'The file size per document should not exceed 25MB.'If you have multiple documents, please browse and upload your documents one at a time. Once all documents you require appear in the uploaded documentation section, click Finish to continue your application. If you need time to gather your medical records, you can save and return later.

 

Upload file(s)


No files uploaded yet

Health questionnaire


Delete health questionnaire

Health questionnaire progress

  1. Preliminary questions

Mental Health

Have you ever experienced any signs or symptoms of, or are currently receiving, or have ever received counselling, investigations or treatment of any psychiatric or psychological conditions, including anxiety, stress or depression?

*Required fields


*Please advise the name of the medical condition

Provide details


*When did you first experience symptoms?


*When did you last experience symptoms?


*Have you had any investigations and/or received any treatment?

If yes, please provide details


*Have you been referred to a specialist?

If yes, please provide details


Your quote has been saved

Thank you for completing a quote with Accuro Health Insurance. This quote will be valid for 30 days. If you wish to continue, make sure that you complete your application by XX MONTH 20XX.

Please note that if you have a birthday before your policy is issued, the pricing will be affected. We have sent you an email with a link back to your quote. To return, simply click the link in the email and you can continue editing. You can save and return to your quote as many times as you need.

If you have any questions or require any assistance, please contact one of the Accuro team on info@accuro.co.nz or 0800 222 876. We are happy to help.

Your application has been saved

Thank you for starting an application with Accuro Health Insurance - This application will be valid for 30 days from Fri Sep 04 2015. Please make sure that you complete your application by XX MONTH 20XX.

Please note that if you have a birthday before your policy is issued the pricing will be affected.

We will send you an email containing a link to your application so you can return to it when you are ready to continue.

If you have any questions or require any assistance, please contact one of the Accuro team on info@accuro.co.nz or 0800 222 876. We are happy to help.

Expired

This application has expired, please start a fresh application.

If you have any questions please feel free to call us on 0800 ACCURO (0800 222 876) or contact us via email at info@accuro.co.nz

Your application is complete!

Thank you for completing your application, by choosing [productName] you are on your way to making sure you have the protection of health insurance with Accuro.

Shortly you will receive an email outlining what happens next.

If you have any questions please feel free to call us on 0800 ACCURO (0800 222 876) or contact us via email at info@accuro.co.nz

Thank You

We are working on it!

Shortly you will receive an email outlining what happens next.

If you have any questions please feel free to call us on 0800 ACCURO (0800 222 876) or contact us via email at info@accuro.co.nz