Friends Life Protection Account Asthma, Bronchitis, other respiratory disorders Questionnaire Important Notes:
• The information given in this questionnaire is confidential when completed • Please give a full and complete answer to each of the following questions, continuing
your answers on a separate sheet of paper if there is insufficient space
• Please fill in this questionnaire using CAPITAL LETTERS and black ink
It is important that the answers given to the questions in this questionnaire are,
to the best of your knowledge and belief, true and complete.
If there is any doubt as to whether any information should be disclosed with
regard to the questions in this questionnaire then you should disclose it.
This questionnaire will constitute part of your application to Friends Life and
failure to reply accurately and completely to the questions in this questionnaire
may result in the non-payment of a claim and may also result in cancellation of
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In what circumstances is an attack brought on? E.g. exercise, stress, allergy
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Please state what medication you have received in the past. E.g.
Becotide, Bricanyl, Franol, Intal, Ventolin
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What treatment are you taking now? E.g. tablets and/or inhalers.
Please give name, dosage and frequency of use.
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have you ever taken steroids? E.g. Prediscolone, Pulmicort (Please circle)
If Yes, please provide details e.g. type of steroid, dates and dosage
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Are you having follow up checks? (Please circle)
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Have you ever been admitted to hospital as an emergency? (Please circle)
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Have you been off work with this complaint? (Please circle)
If Yes, please provide details e.g. dates and duration
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Do your symptoms wake you up at night? (Please circle)
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If you use a peak flowmeter and record the results, please quote your lowest and highest reading in the last 3 months
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Declaration
I confirm that the answers I have given to the questions in this questionnaire are, to
the best of my knowledge and belief, true and accurate.
I am aware that if I am in any doubt as to whether any information should be
disclosed with regard to the questions in this questionnaire then I should disclose it.
I agree that this questionnaire will constitute part of my application to Friends Life
and that failure to reply accurately and completely to the questions in this questionnaire may result in cancellation of my policy by Friends Life.
I will tell Friends Life immediately if there are any changes to the information I have given, or should have given, before the account starts. I understand that failure to do so may result in the contract being declared void, and that a claim for the proceeds may not be paid.
Friends Life, PO Box 1810, Bristol BS99 5SN. Telephone number 0117 989 9000 Friends Life Limited An incorporated company limited by shares and registered in England and Wales, number 4096141. Registered office: Pixham End, Dorking, Surrey RH4 1QA. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Telephone calls may be recorded. Friends Life is a registered trade mark of the Friends Life group. PRUW23 18/07/2013
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IMAGINE INTERNATIONAL ACADEMY OF NORTH TEXAS World -Class C oll ege Preparatory Edu cati on www.imaginenorthtexas.org STUDENT MEDICATION REGULATIONS The Imagine International Academy of North Texas recognizes that it will occasionally be necessary for a student to take medication at school. Parents should make every effort to schedule medication outside the school day. When admin
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