Needs Analysis Questionnaire

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Examination…   Diagnosis…   Prescription…

Answering the questions below is necessary to examine your needs, wishes, requirements and problems concerning your health care cover. On the basis of your answers, I shall make a diagnosis and give you my prescription as to what you must do. With clarity, sincerity and absence of hype, so that you can make an informed decision.

Please answer all the questions, in the blank spaces, giving full particulars. If something is not applicable, type N/A. When done, click Send at the bottom hereof.

The contributions of many options are based on monthly income. This provides an opportunity for lower income earners to obtain excellent cover at really affordable contributions per month. Therefore, the two questions below regarding gross income, if below R15 000 per month.

I treat all your information with the utmost professional secrecy.

You hereafter means not only yourself, but also each of your dependents you wish to register under your membership.

Needs analysis Questionnaire

Your Name and Surname

Your email address

Land-line at home (In format 000 000 0000)

Land-line at work (In format 000 000 0000)

Cellphone (in format 000 000 0000)

Where are you situated: town/nearest town; or suburb and city

Your age

Spouse (if beneficiary) Name, Surname and age

Child beneficiaries: Names, (B)Boy/(G)Girl, ages

During the past year:
Have you been hospitalized
Diagnosed with any medical condition
Treated for anything
Do you suffer from any chronic diseases
Did you consult with any medical service providers
Regarding the foreseeable future:
Are you aware of any operation/treatment you still have to undergo

If "yes" to any question: Conditions, dates, treatment, medication, costs...

Females: Currently pregnant or planning to fall pregnant

If "yes" : Weeks, due date, problems, Caesarian/normal, planning for...

Do you regularly travel outside the RSA's borders

Which sports do you and your beneficiaries partake in

Are you a member of a gymnasium / Would you like to join one

Do you smoke and, if so, would you like to stop

Your current Medical scheme/option/contribution pm

Your spouse's scheme/option/contribution if on a different scheme

What problems are you experiencing with your current scheme

Details of any existing late joiner penalties and/or waiting periods

Total years/months you have belonged to medical schemes since age 21

Total years/months your spouse has belonged to schemes since age 21

Describe the ideal medical scheme you would like to join

Details of your gap, dread disease, income protection, funeral cover...

Are you a member of PPS; or do you qualify for membership

Your tertiary qualifications

Your current profession/vocation

Contribution out of own pocket you would not like to exceed pm

Is your contribution subsidised pm and if so, by how much

Your gross income per month (if below R15 000 pm)

Your spouse's gross income per month (if below R15 000 pm)

Anything else you want to tell me now; Any questions at this stage

Where or from whom did you hear of me

Thank you!

I will be in touch with you real soon.

Contact me

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heindeBruin_04_print_03 - Kopstuk B.Proc.  N.Dip.(Marketing)
Financial Services Provider — Licence 8840
Health Care Broker  — Accreditation BR 285
Accredited  PPS Broker — B/Code 124314907

hein@moeitedoener.co.za

053 531 0003  Office
053 531 0123  Office
082 953 3222  Cellphone (24 hours)
086 671 2107  Fax

PO Box 123 / 8 Karee Street  BARKLY WEST 8375
On the banks of the Vaal River, 35 km from Kimberley

Always as near to you as the nearest phone or computer

Language Editor Dr. Lariza Hoffman

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