Mortgage Protection – MINI MEDICAL SCREEN

Mortgage Protection - MINI MEDICAL SCREEN

First Name

Surname

Your Height?

Your Weight?

Waist Size / Dress size?

How many Units of Alcohol Consumed in 1 week? (glass of wine, measure of spirit, half pint beer = 1 unit)

Smoked Cigarettes in last 12 months? (Or used any Nicotine product such a vape, patches or gum)

Yes

No

Do you take medication for High/Low Blood Pressure?

Yes

No

Do you take Medication for High/Low Blood Sugar?

Yes

No

Do you take Medication for High Low/Cholesterol?

Yes

No

Do you take Medication for Anxiety or Depression?

Yes

No

Do you take Medication for Any Other Condition?

Yes

No

Are you awaiting the results of any tests, or investigations from any health professional?

Yes

No

Have you ever been diagnosed with cancer, stroke, heart attack or any other serious condition?

Yes

No

If you are human, leave this field blank.

"It was quite an easy decision to make.... the run of the mill mortgage brokers really were not going to be able to help me on this one. I would recommend Capital Fortune to anyone asking."

Joe Crosby, Golders Green

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