Details of the person making the medical declaration
Mr Mrs Miss Ms Dr Prof. Rev.
Are you making this declaration on behalf of someone else? *
e.g. son or daughter, or a family member who is unable to complete the form themselves.
Reason for completing the form on someone else's behalf
Please provide the GP with as much information as possible
Phone Declaration Questionnaire (21 Questions)
To be completed by all applicants
Have you ever suffered at any time from diseases of the heart and circulation including high blood pressure (or taking tablets for high blood pressure), angina, chest pains or palpitations?
Have you ever had heart surgery?
Have you ever had significant bleeding or blood disorders?
Have you ever suffered from or had to take medication for Asthma?
Have you ever had collapsed lung or pneumothorax?
Have you ever had any other chest or lung disease or problems?
Have you ever suffered from blackouts, fainting or recurrent dizziness?
Have you had regular ear problems in the last 10 years?
Do you have an ileostomy, colostomy, or ever had a repair of the hiatus hernia?
Have you ever had epilepsy or fits?
Have you ever had recurrent migraines?
Have you ever had any other disease of the brain or nervous system (including strokes or multiple sclerosis)?
Have you had a head injury with loss of consciousness in the last five years?
Have you ever had any back or spinal surgery? Or had any serious back problems?
Have you ever had any mental or psychological illness of any kind, fear of small places, crowds, or panic attacks?
Have you ever had any problem with alcohol or drug abuse in the last five years?
Do you have diabetes?
Are you taking any prescribed medication (except the contraceptive pill)?
Are you currently receiving medical care or have you consulted a doctor in the last year other than for trivial issues e.g. common cold or minor injury?
Have you ever been refused any medical certificate or life insurance, or been offered special terms?
Have you ever had, or been treated for, decompression illness?
Any other information
Please consider giving the GP any additional information that will help process your request.
Consent * CAPTCHA
To be signed by the requesting patient