Have you smoked in the last 12 months? 
Drug/Alcohol Questionnaire

        

                                                                            

                                                                                        

                                                                                              

                                                                                              

                                        

Present drug/alcohol daily consumption?                           

Past drug/alcohol daily consumption?                                 

When did you last have drugs/alcohol?                               

What type/s of drugs have you used?                          

                                                                                               
                                                                                                                                              

Full name:                                                                                      

Phone no:                                                                             

Email address:                                                                      

Best time to be contacted:                                                 

 

 

       

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Special Risk Managers Pty Ltd is a member firm and corporate authorised representative of Count Financial Limited ABN 19 001 974 625 AFSL 227232

Date of Birth:
Height:
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Type of insurance you want:
What treatment did/do you receive for this condition?
Have you ever been diagnosed as having a liver or pancreas related disorder?