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MedQs2023
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Membership number
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Member SA ID number
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Email Adddress
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Email
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Contact number
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Suburb
City
Your Province
Select your province
Eastern Cape
Free State
Gauteng
KwaZulu Natal
Limpopo
Mpumalanga
Northern Cape
North West
Western Cape
Current medical aid
Current option on medical aid
Membership number
Do you have dependants on your medical aid?
Yes
No
If yes, what are their ages?
What is your family gross income?
What is your affordability for medical aid?
Current gap cover
Current option on gap cover
Have you, or any of your dependents been in hospital in the last 12 months?
Yes
No
If yes, what for?
Have you or any of your dependents had cancer before?
Yes
No
Is there a history of cancer in your family? E.g. parents, siblings
Yes
No
Do any of you have any other serious health problems for example kidney issues, heart problems, diabetes etc.
Yes
No
Please specify the health issues
Are you planning any procedures in the next 12 months?
Yes
No
If yes, please specify what these are?
How many people in the family wear glasses or contact lenses?
Do you have any special dental needs? e.g. orthodontics, implants, dentures.
Yes
No
Are you taking monthly medication for a chronic condition?
Yes
No
Name of condition/s
Medication/s used
How often do you make use of other services? e.g. physiotherapist, chiropractor etc
How many dental visits do you have?
Can you estimate how much you spend at a pharmacy each month?
Do you want an option that allows you to go to any hospital you like?
Yes
No
Do you want an option, at a lower premium, where you must use a hospital on the medical aid's list?
Yes
No
Do you want to be able to get your medication from any pharmacy?
Yes
No
Or, are you happy to be limited to the provider the medical aid prefers?
Yes
No
Do you need cover for wisdom teeth extraction in hospital?
Yes
No
Are you interested in loyalty programmes like Vitality and Multiply?
Yes
No
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