Name* First Last Email* If you are getting advice as a couple, please complete this questionnaire individually for each of you.Date of Birth* Day Month Year Height* Weight* Main Occupation* Employer* Start date at this Employer* Day Month Year Hours worked per week* Annual Gross Salary* Nature of duties at work?*As a percentage, how much time do you spend on each of these duties? Admin/Clerical?_______% Light Manual (eg. driving/lifting under 5kg)?____% Supervisor of Manual Work?____% Manual Work (lifting over 5kg/cleaning etc)?____%How long have you been in this occupation? (include same occupation with different employers)* Less than 6 months 6-12 months 1-3 years More than 3 years Do you have a second occupation?* Yes No How many hours per week? Have you ever been declared bankrupt, or have any entities owned or controlled by you been placed under administration, receivership or into liquidation?* Yes No Any planned changes to your occupation in the next 12 months?* Yes No If yes, please explain? Does your occupation involve any of the following?* Lifting or moving heavy goods without the use of machinery? Working underground? Working offshore and/or underwater? Working at heights over 10 meters Working with chemicals, gases or radioactive substance? Working with explosives and/or high voltage electricity? None of the above Have you smoked tobacco, cigars or a pipe, or any other substance within the past 12 months, or used nicotine replacement treatment in the last 3 months?* Yes No Do you currently engage in, or intend to engage in any of the following pursuits, pastimes or activities? Any type of football (including rugby, touch, soccer, Aussie Rules)?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Motor sports (including trail bike riding)* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Recreational activites involving heights (including rock climbing, abseiling, mountaineering, parachuting, hand-gliding)?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Combat sports (including boxing, martial arts, mixed martial arts)?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Underwater recreational activities (eg scuba-diving)?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Water Sports (including water-sking, canyoning)?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Underground activities (eg caving)?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Flying (not including as a fare-paying passenger)?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Skiing, snowboarding or skating?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Any other competitive sport?* Yes No If yes, provide details:*What activity? Frequency? Recreational/Amateur/Professional? Have any of your BLOOD-RELATED parents, brothers or sisters been diagnosed with or suffered from any hereditary conditions (eg cancer, heart attack, diabetes, Alzheimer's)?* Yes No If yes, provide details:*Who? What Illness? Age of Diagnosis? Comments? SHARE