From what date do the patient's records in your possession begin? If this period is not continuous, please give reasons (if you know them) for any gaps.

Date Patient Records held from - Last Medical History Record where Read Code is 9R8..00 (Date records held from) if a 9R8 record exists. If the Comments field on the 9R8 record is blank, then "Date patient registered" will appear on the report. If there is text in the Comments field, then the text will appear on the report. If a date is written in the Comments field, then on the report "Date records held from" will appear.

If there is no 9R8 record, then "Date patient registered" will appear on the report.

OR

Date Patient registered

Is the patient currently receiving medical care, medication or treatment, including repeat prescriptions (NHS or private)? Yes/No

If yes please give details of all relevant prescribed drugs and dosages here, if not listed below:

Are you waiting for the results of any referrals or tests? Yes/No

If yes please give details of relevant referrals or tests here if not listed below:

Consultations in last three months, includes all therapy and referrals

Date of Consultation, Type of Consultation, Clinician and Detail of Consultation

All general clinical information, tests, therapy, referrals, letters, immunisation and recalls recorded against consultations within the last 3 months will be listed.

List of repeat medication issued in the last three months

Date of last Issue, Drug Name, Quantity, packsize and dosage

List of all acute medication issued in the last three months

Date of Issue, Drug Name, Quantity, packsize and dosage

Please give details of any relevant certified time off work the patient has taken in the past three years. (Please give details of length of time off and the reason)

All Medical History Records (Date, Read description, Comments) where the Read code is:

• 9D1 MED3 - doctor's statement
• 9D2 MED5 - doctor's special stat.
• 9D3 MED6 - vague diagn stat to RMO
• 9D4 RM& - refer patient to RMO
• 9D5 Private sickness certificate
• 9DC SCI - self certificate admin.
• 9DG IB74 Incapacity benefit
• 9DF MED4 Doctors statement
• ZV680 [V] Issue of medical certificate

If the patient has had any relevant illness, trauma, referrals for specialist advice or treatment, hospital admissions, consultations with you, or any other medical adviser, therapist or counsellor, please give details. As insurers we are usually concerned with rates of death and disease over the longer term. In particular, we are interested in the following:

• Malignancy, cardiovascular disease, diabetes, and degenerative diseases
• Musculoskeletal disease or injury, for example, arthritis, rheumatism, back problem or any other disorder of the joints or muscles
• Anxiety state, depression, neurosis, psychosis, stress or fatigue
• Suicidal tendencies or attempts
• Conditions related to drug or alcohol misuse or smoking or chewing tobacco

You should not include any history of sexually-transmitted infections unless there are long term health implications. You should not include information about whether the patient has had a negative HIV or Hepatitis B or C test, or had counselling in connection with this type of test.

• Active Problems
  • All active Problem Header Records (Start Date, End Date, Description)
• Significant history
  • All Medical History Records (Date, Read Description, Comments) with a priority of 1 or 2, excluding Read Codes:
    • 9N32 Third party encounter
    • 43C HTLV-3 antibody test
    • 43X4 Hepatitis C antibody test negative
    • 43B3 SH-antigen negative
    • 43B7 Hepatitis C non-immune,
    • 14OP At risk of sexually transmitted infection
    • 14OZ H/O: risk factor NOS , , , , , ,
    • plus Administration history
• Other relevant history
  • All Medical History Records where the priority is 3 or over (Date, Read description, Comments)
• Referrals
  • All Referrals Records (Date, referred for, Hospital/provider)
• Treatment and medication issued in the last two years
  • All Acute and Repeat Issue Therapy except Antibiotic and infection drugs and non drug items (Date, Name of medication, Quantity and dosage) excluding therapy issued in the last 3 months which is listed at the beginning of the report

• Height, weight and BMI in last two years:
  • Latest Height Record within the last 2 years - Date, height
  • All Weight Records within the last 2 years - Date, Weight, BMI
• Smoking and Alcohol in the last five years
  • All Alcohol Records within the last 5 years - Date, Read Description, Consumption per week or Comment
  • All Smoking Records within the last 5 years - Date, Read Description, Amount per day or comment
• Smear and colposcopy data (only for females who are 20 or more years old)
  • All Cervical Cytology Records for females 20 years and over within the last 5 years where the smear was adequate (Date, Read Description
  • All Medical History Records - (only for Date, Read Description for females 20 years and over that in the last 5 years who have Read codes:
    • 7E01 Destruction of lesion of cervix uteri
    • 7E00 Excision of cervix uteri
    • 7D1C2 Colposcopy NEC
    • 8H7N Refer for colposcopy
    • 9N1e Seen in colposcopy clinic
• Biochemistry
• Lipids - Date, Read Description, Numeric Value and Units
  • All Serum cholesterol Records
  • All High Density Lipoprotein Records
  • All Low Density Lipoprotein Records
  • All Triglycerides Records
• Blood glucose & HBA1c- Date, Read Description, Numeric Value and Units
  • All Blood glucose Records
  • All Fasting glucose Records
  • All HbA1C - Diabetic control Records
  • All Fructosamine Records
• Liver Function Tests - Date, Read Description, Numeric Value and Units
  • All Alkaline Phosphatase Records
  • All Gamma Glutamyl Transpeptidase Records
  • All Aspartate Aminotransferase Records
  • All Alanine Aminotransferase Records
• Prostate Function (for males only) - Date, Read Description, Numeric Value and Units
  • All Prostate Specific Antigen Records
• Renal Function - Date, Read Description, Numeric Value and Units
  • All Renal Arteriography Records
  • All Serum creatinine Records in Ascending order
  • All Urea - blood Records in Ascending order
• Haematology - Date, Read Description, Numeric Value and Units
  • All Erythrocyte sedimentation rate Records
  • All Haemoglobin Records
  • All Mean corpuscular haemoglobin Records
• Pathology, Histology and Biopsy - Date, Read Description, Numeric Value and Units
  • All Histology Records
  • All Sputum Cytology Test Records
  • All Genetic Observations Records
  • All Other Laboratory tests Records
  • All Nerve Conduction Studies Records
• X-Rays and ECGs - Date, Read Description, Numeric Value and Units
  • All Test results within the last 5 years with read codes starting 5 (Radiology/physics in medicine) or 32 (Electrocardiography)
• Urine analysis - Date, Read Description, Numeric Value and Units
  • All Urinalysis Glucose Records
  • All Urine dipstick for glucose Records
  • All Urinalysis Protein Records
  • All Urine dipstick for protein Records
  • All Urine dipstick for blood Records
  • All Test results with a read code of 46 (Urine examination)
• Other - Date, Read Description, Numeric Value and Units
  • All Ambulatory blood pressure Records
  • All Doppler Ultrasound Peripheral Pulse Records
  • All Echocardiogram Records
  • All PF current Records
  • All Lung Func before bronchodilation Records
  • All Lung Func after bronchodilation Records
  • All Lung function pre steroids Records
  • All Lung function post steroids Records
  • All Forced Expiratory Volume in 1 sec Records
  • All Forced Vital Capacity Records
  • All Total Lung Capacity Records
  • All FEV1/FVC Records
  • All Airway Reversibility Records
  • All Spirometry Records
  • All Endoscopy Records
  • All Oesophagoscopy Records
  • All Duodenoscopy Records
  • All Colonoscopy Records
  • All Sigmoidoscopy Records
  • All Bronchoscopy Records
  • All Nerve Conduction Studies Records
  • All Electroencephalography Records

Has the patient had any blood pressure reading taken in the last three years? If 'Yes', please give details. If a blood pressure reading resulted in treatment please give the post-treatment reading(s) if known

• All Blood pressure Records within the last 3 years - Date, Systolic, Diastolic

We have asked the patient whether any of his or her first degree relatives (parents or siblings) have had heart disease, stroke, diabetes, cancer, multiple sclerosis, Alzheimer’s disease or any other familial condition before the age of 65. The patient has also given permission for you to confirm whether the medical record shows that he or she has revealed information about a relevant family history to a health care professional.

If the medical records show that the patient has told you, or another health care professional, about any of these conditions in a first degree relative, please give details, including age it began, here. You must not reveal any information about the patients’ family members that came from any source other than the patient who this report is about.

• All Family History Records - Date, Read Description, Comments

Insurance companies must provide, if asked, written reasons to their clients for:

• the premiums they charge;
• reducing the insurance cover that is provided;
• refusing an insurance application;
• rejecting a claim; or
• cancelling a policy.

The Chief Medical Officer explains the company's reasoning. We will tell people who want to discuss the health implications of anything that is revealed during the insurance process to contact you, their GP. You will not have to explain actuarial or underwriting decisions.

Is there any information in your report that our Chief Medical Officer should not release to the patient, because this would cause serious physical or mental harm to the patient or another person? Yes/No

If 'Yes', please give details.

Additional Information

I confirm that I have checked this report and updated any information as required from the manual records and that, to the best of my knowledge and belief, the information contained in the report is complete and up-to-date.

Signed_____________________________________________

Name______________________________________________

Qualifications________________________________________

Date_______________________________________________

Payment Details

Cheque payable to ___________________________________

Account Name_______________________________________

Account Number______________________________________

Sort Code___________________________________________