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Medical questionnaire

We know – there are a lot of questions here. But they're all important. Please consider each one carefully and provide accurate, complete answers.

To complete your application, you will need to fill in all the blanks, unless they're marked "optional."

Medical declaration

Sometimes, we can't offer coverage based on your or your family's medical history. But often we can make changes that make it possible for us to provide you with the protection you need – for example, by excluding expenses related to certain conditions or charging a higher premium.

IMPORTANT: Any reference to testing, tests, test results, or investigations in this section excludes genetic tests.

Genetic test means a test that analyzes DNA, RNA or chromosomes for purposes such as the prediction of disease or vertical transmission risks, or monitoring, diagnosis or prognosis.

Have you, your co-applicant or any listed dependent ever consulted a physician or qualified health care practitioner about, been treated for, or had any known indication of:

High blood pressure, high cholesterol, any circulatory or blood disorder

Yes No

Heart or blood vessel disorder, heart murmur, chest pain, angina, stroke or transient ischemic attack (TIA)

Yes No

Back, neck, disc, hip, knee or joint pain or disorder, fibromyalgia, osteoporosis, osteopenia, chronic pain, paralysis, weakness or numbness or any other musculoskeletal pain or disorder

Yes No

Digestive system disorder, crohn’s disease, ulcerative colitis, liver disease or disorder including hepatitis or hepatitis carrier state

Yes No

Mental, nervous, emotional or neurological disorder including depression, anxiety, attention deficit disorder or stress

Yes No

Alcohol or drug abuse, or any addiction

Yes No

Allergies, asthma, bronchitis, respiratory disorder, shortness of breath or sleep apnea

Yes No

Immune disorder including testing for acquired immune deficiency syndrome (AIDS), human immunodeficiency syndrome (HIV)

Yes No

Arthritis, rheumatism or rheumatoid arthritis

Yes No

Cancer, tumor, cyst, polyp or any growth

Yes No

Skin disorder

Yes No

Breast disorder, menopause, reproductive disorder, infertility or assisted conception

Yes No

Bladder, kidney or prostate disorder or other genitourinary disorder

Yes No

Headaches or migraines

Yes No

Diabetes, endocrine disorder, pituitary or thyroid disorder or lupus

Yes No

Eye or ear disorder

Yes No

Any other complaint, condition, disease or disorder

Yes No

Have you, your co-applicant or any listed dependent ever been treated for, hospitalized or had any known physical impairments, congenital abnormality, medical condition, disease or disorder not stated above?

Yes No

Have you, your co-applicant or any listed dependent ever been advised to have an investigation, hospitalization or surgery which has not been completed?

Yes No

Have you, your co-applicant or any listed dependent been on disability or been unable to perform normal daily activities for a minimum of 2 weeks within the last 5 years?

Yes No

Do you, your co-applicant or any listed dependent currently use or expect to use in the next 3 months, or have you discontinued use in the last 3 months of any drug, medication, serum or other treatment?

Yes No

Are you, your co-applicant or any listed dependent pregnant?

Yes No

Name of person

Due date

Day

Month

Year

Invalid Date

If you don’t have space to answer any question completely, please call us to give us the extra information.

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Medical questionnaire

Medical declaration

Questions?

Questions?