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Online Application

First Person

Second Person

Doctors Name and address*

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What is your occupation?*

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Occupation Information
Is your occupation 100% administration/supervisory/managerial?*

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Does your occupation involve work at sea, work underground or use of explosives?*

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Do you work at heights above 50 feet?*

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Risk Assessment

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Second Person

Where were you born?*

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What nationality are you?*

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Have you smoked cigarettes, cigars or pipe tobacco in the last 12 months?*

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If ‘Yes’ how much do you smoke each day or if you have stopped smoking within the last 12 months how much did you smoke each day?*

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How much alcohol do you drink each week?*

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Unit guide: Pint beer=2.0 units--Bottle beer=1.5 units--Measure spirits=1.0 units--Bottle wine=7.0 units--Glass wine=1.0 units
What is your height?*

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What is your Weight?*

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Some details about your medical history:
Do you currently have or have you ever had any of the following:

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Second Person


A. Heart attack, angina, heart bypass surgery, heart valve disorder, heart murmur, angioplasty, heart related chest pain or any other heart disease or disorder?*

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Please Give Details*

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B.Problems with the aorta, poor circulation in the legs or problems with the arteries excluding cholesterol?*

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Please Give Details*

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C.Cancer, malignant tumour, leukaemia, Hodgkin’s disease, Non Hodgkin’s disease, Lymphoma or any brain or spinal tumour?*

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Please Give Details*

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D.Schizophrenia, bipolar affective disorder/manic depression, psychosis, paranoia or mania?*

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Please Give Details*

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E.Stroke, TIA or mini stroke, brain haemorrhage, brain or spinal cord injury, coma or amnesia?*

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Please Give Details*

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F.Multiple sclerosis, Parkinson’s disease, motor neurone disease, cerebral palsy, muscular dystrophy, Alzheimer’s disease, dementia or Huntington’s disease?*

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Please Give Details*

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G.Paralysis, numbness or tingling in the limbs or face, tremor, temporary loss of muscle power or lack of co-ordination, double/blurred vision or optic neuritis?*

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Please Give Details*

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H.Diabetes, sugar in the urine, raised blood sugar, low blood sugar or glucose intolerance?*

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Please Give Details*

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I.Hepatitis. Cirrhosis of liver. other liver disorders, pancreatitis, ulcerative colitis, Crohn’s disease or removal of part or all of the bowel/colon?*

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Please Give Details*

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J.Have you ever had treatment or counselling for alcohol excess or misuse or have you ever been advised by a medical practitioner to cease or reduce your alcohol consumption?*

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Please Give Details*

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K.Have you ever used any recreational drugs such as cannabis, cocaine, heroin, ecstasy, amphetamines, anabolic steroids or non-prescription sedatives?*

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Please Give Details*

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L.Have you ever tested positive for HIV or are you awaiting the result of a HIV test?*

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Please Give Details*

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M.Within the last five years have you tested positive for, or been treated for any disease which was transmitted sexually?*

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Please Give Details*

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In the last 5 years have you had or do you currently have any of the following:

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Second Person

a. Asthma, bronchitis, emphysema or any other lung or breathing disorder? *

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Please Give Details*

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b.High blood pressure, raised cholesterol or low blood pressure?*

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Please Give Details*

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c.Depression, stress, anxiety, eating disorders, chronic fatigue syndrome or other nervous or mental disorder?*

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Please Give Details*

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d.Epilepsy, seizure, fit, fainting, dizziness, blackouts, severe headaches, migraines, concussion, meningitis or encephalitis? *

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Please Give Details*

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e.Back and neck disorders including disc problems, sciatica, whiplash, diseases of the spine, back and neck pain or trapped nerves? *

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Please Give Details*

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e.Back and neck disorders including disc problems, sciatica, whiplash, diseases of the spine, back and neck pain or trapped nerves? *

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Please Give Details*

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g.Disorder of the digestive system or stomach, including reflux, ulcers, hernia, oesophagitis, or Coeliac disease?*

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Please Give Details*

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h.Thyroid problems, goitre or glandular fever?*

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Please Give Details*

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i.Disorder of the eyes that is not corrected by spectacles or contact lenses including: impaired vision, blindness, cataract or glaucoma?*

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Please Give Details*

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j.Disorder of the ears, nose or throat including: hearing impairment/ deafness or vertigo?*

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Please Give Details*

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k.Anaemia, blood clotting disorders, haemophilia, haemochromatosis, thalassaemia or other blood disorders? *

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Please Give Details*

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l.Kidney stone(s), disease or surgery, prostate problems, testicular problems or abnormal urine test results? (male only)*

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Please Give Details*

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-Kidney stone(s), disease or surgery or abnormal urine test results? (female only) *

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Please Give Details*

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m.Abnormal smear teat results, menstrual disorders, hysterectomy, endometriosis, fibroids, ovarian cysts or mammogram which has required further investigation?*

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Please Give Details*

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n.Have you had any medical investigations, scans or tests within the 5 last years?*

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Please Give Details*

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o.Are you receiving or awaiting ongoing medical treatment, referral, medical investigation, test results, surgical procedure or intending to seek medical advice or treatment.*

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Please Give Details*

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Have any of your biological parents, brothers or sisters had any of the following medical conditions before the age of 65:

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Second Person

Concerning your family:
a.Cancer of the breast, ovaries, colon, bowel, rectum, stomach, polyposis of the colon or any other form of cancer*

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Please Give Details*

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b.Heart attack, angina, heart by-pass, angioplasty, heart failure, cardiomyopathy, stroke, diabetes, haemochromatosis, high blood pressure or raised cholesterol?*

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Please Give Details*

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c.Multiple sclerosis, Huntington’s disease. Polycystic kidney disease, motor neurone disease, muscular dystrophy, Parkinson’s or Alzheimer’s disease?*

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Please Give Details*

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d. Apart from the conditions listed above. Have 2 or more of any of your biological parents, brothers or sisters had the same condition before the age of 65?, motor neurone disease, muscular dystrophy, Parkinson’s or Alzheimer’s disease?*

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Please Give Details*

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e. Other than a genetic test have you undergone or been advised to have any specific tests or investigations as a result of a condition one of your biological parents, brothers or sisters had?*

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Please Give Details*

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About your travel and interest
a.In the last 10 years, have you spent more than 6 months outside of Ireland, the EU, North America, Japan, Singapore, Hong Kong, New Zealand or Australia?*

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If yes where and how long?*

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b.In the next 12 months, do you intend to travel or reside for more than 30 days outside of Ireland, the EU, North America, Japan, Singapore, Hong Kong, New Zealand or Australia?*

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If yes give country(ies), date, duration, and purpose*

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c.Do you take part in or intend to take part in any hazardous leisure activities or sports such as scuba diving, motor sports, aviation, water sports, horse riding, martial arts, mountaineering, caving or winter/ice sports?*

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Please Give Details*

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Previous Application(s)
Have you ever had an application on your life declined, postponed, accepted at an increased premium or with an exclusion imposedfor any death, specified or critical illness or disability benefit? *

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Please Give Details*

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Name*

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Confirm Date of Birth*

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I have read and understand the replies to all the questions in this application and declare that all statements herein are true to the best of my knowledge.*

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