### Anonymous Pre-assessment:

### Life Insurances for people living

### with diabetes or elevated blood sugars

   Have you received a diabetes diagnosis? \*   Yes

  No

   Type of diabetes diagnosis \*

 Please select ...

  What was your most recent HbA1c result? \*

 Please select ...

 * Tip HbA1c is your average blood glucose (sugar) levels for the last two to three months. If you have diabetes, an ideal HbA1c level is 48mmol/mol (6.5%) or below.

  How do you manage your condition \*

 Please select ...

   Are you keeping to your current treatment plan? \*   Yes

  No

    Have you ever taken more than 2 weeks off work for diabetes related issues? \*   No

  Yes

 * Tip: Specifically for diabetes or high blood sugars health issues

    Have you also been diagnosed with Hepatitis C? \*   No

  Yes

    Do you also have a current mental health diagnosis?   No

  Yes

 * eg: Have you been prescribed talk therapy or meds

    Do you have any other related medical condition? \*   No

  Yes

 * eg: Retinopathy, Neuropathy or Nephropathy

   List other related medical conditions below

 Please tell us more about what conditions you're living with so we can better understand your situation, please.

   Were you first diagnosed for diabetes outside of Australia? \*   No

  Yes

   If first diagnosed outside Australia, please specify region \*

 Please select ...

  If first diagnosed outside Australia, when did you begin treatments? \*

 Please select

  How would you describe your gender?

 Please select ...

  What is your age range? \*

 Please select

  How long have you been living with a positive diabetes diagnosis? \*

 Please select ...

  How long have you been receiving treatment? \*

 Please select ...

  What is your height? \*

 Please select ...

  What is your weight? \*

 Please select ...

  Is your current BMI ratio above 35? \*

 Please select ...

 * Tip: Body mass index is weight in kgs divided by height in cms

  Do you currently smoke? \*

 Please select ...

 * Tip: Smoking includes vaping

  Specify other related medical condition \*

   Do you currently use recreational drugs (other than Cannabis)? \*   No

  Yes

    Please specify recreational drugs currently \*   Crystal Meth

  Heroin

  Other

    Do you currently inject recreational drugs? \*   No

  Yes

   What was the last time you injected recreational drugs? \*

 Please select

   Is there any other relevant information you would like us to know? \*   No

  Yes

   Please specify any other information you'd like us to know \*

   Have you been refused or declined insurance in the last 12 months? \*   No

  Yes

  Heads Up: *Just letting you know, this may be a tough one and might take a little more time than usual to assess.
Please click to pre-assess then send us an email from the next page.*

`Version:{year}|{month}`