About us
Meet the team
Services
Mortgages
First time buyers
Remortgages
Self-employed mortgages
Moving house
Buy-to-let
Mortgage terms explained
Protection
Personal protection
Business protection
Tools
Mortgage calculator
Overpayments calculator
Other Services
Equity release
Credit report
Home insurance
Will estate planning
Refer a friend
Book appointment
Back
Health questionnaire
Fill out this quick form and we’ll find the most competitive life insurance options for you.
Get started
Applicant details
Full name
Date of birth
Email
Telephone
Address
GP name and address
Add background infomation
Applicant background information
Occupation
Annual income
Height (cm or ft/in)
Weight (kg or st/lb)
Do you currently smoke or vape, or have you smoked, vaped, or used any nicotine or tobacco products within the last twelve months?
Yes
No
Do you ride a motorbike?
Yes
No
Proceed to health questions
Add another applicant
Additonal applicant details
Full name
Date of birth
Email
Telephone
Address
GP name and address
Add background information
Additional applicant background information
Occupation
Annual income
Height (cm or ft/in)
Weight (kg or st/lb)
Do you currently smoke or vape, or have you smoked, vaped, or used any nicotine or tobacco products within the last twelve months?
Yes
No
Do you ride a motorbike?
Yes
No
Proceed to health questions
Health and lifestyle questions
Heart attack, chest pain, palpitations, heart murmur, high blood pressure, high cholesterol, stroke, or any disease or abnormality of your heart, arteries or veins?
Applicant 1
Yes
No
Applicant 2
Yes
No
Cancer, tumour, mole or any other growth, or lump, either malignant or benign, or leukaemia, or are you aware of any lump or growth for which you have not yet sought medical advice?
Applicant 1
Yes
No
Applicant 2
Yes
No
Multiple sclerosis, optic or retrobulbar neuritis, any possible disorder of your brain or nervous system, or any disease affecting your muscles?
Applicant 1
Yes
No
Applicant 2
Yes
No
Diabetes or sugar in the urine?
Applicant 1
Yes
No
Applicant 2
Yes
No
Arthritis, rheumatism or any form of neck, back or spinal trouble, or any joint problems?
Applicant 1
Yes
No
Applicant 2
Yes
No
Any form of nervous or mental disorder, or have you ever required tranquillisers, antidepressants, or medication for psychological conditions?
Applicant 1
Yes
No
Applicant 2
Yes
No
Any problem, disease or abnormality affecting your lungs, stomach, bowel, bladder, kidneys or liver?
Applicant 1
Yes
No
Applicant 2
Yes
No
Have you ever tested positive for HIV, AIDS, Hepatitis A, B, or C, or are you awaiting the results of such a test?
Applicant 1
Yes
No
Applicant 2
Yes
No
Any problem, disease or abnormality affecting your ears, hearing or balance, or your eyes or vision, not wholly corrected by spectacles or lenses?
Applicant 1
Yes
No
Applicant 2
Yes
No
With the exception of donating blood or routine vaccinations, have you ever had a blood test, medical investigation, or counselling at a hospital or clinic for any other medical condition or illness not already mentioned?
Applicant 1
Yes
No
Applicant 2
Yes
No
Are you currently having any treatment for any medical or psychiatric condition not previously mentioned?
Applicant 1
Yes
No
Applicant 2
Yes
No
Have you ever had any illness, injury, or disability not previously mentioned, which has kept you off work for a total of two weeks or more?
Applicant 1
Yes
No
Applicant 2
Yes
No
Have any of your parents, brothers or sisters, before the age of 65, died or suffered from diabetes, heart disease, stroke, kidney disease, cancer, multiple sclerosis, paralysis, brain disorder, or any hereditary illness?
Applicant 1
Yes
No
Applicant 2
Yes
No
Are you currently receiving any medication for a medical condition?
Applicant 1
Yes
No
Applicant 2
Yes
No
Do you take part in any hazardous sports or pastimes, such as skydiving, parachuting, skiing, horse riding, diving, or similar activities?
Applicant 1
Yes
No
Applicant 2
Yes
No
I consent to Watt Mortgage storing and using my data for advice and insurance application purposes.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
