Medical Declaration
All applicants of age 55 to 85 on the effective date are required to complete the medical declaration for the Enhanced Plan.
Please answer the following yes/no questions:
Q1. Within the past 12 months, and in relation only to the medical conditions listed below, have you:
Any of the following medical conditions:
|
|
Q2. Have you had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure)? | |
Q3. Within the past 12 months have you:
|
|
Q4. Within the past 12 months have you been prescribed or taken any of the following:
|
|
Q5. Within the past 12 months have you been prescribed or taken medications for both diabetes and a heart condition? (Answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition. |
Q1. Within the past 12 months, and in relation only to the medical conditions listed below, have you:
Any of the following medical conditions:
|
|
Q2. Have you had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure)? | |
Q3. Within the past 12 months have you:
|
|
Q4. Within the past 12 months have you been prescribed or taken any of the following:
|
|
Q5. Within the past 12 months have you been prescribed or taken medications for both diabetes and a heart condition? (Answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition. |
Q1. Within the past 12 months, and in relation only to the medical conditions listed below, have you:
Any of the following medical conditions:
|
|
Q2. Have you had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure)? | |
Q3. Within the past 12 months have you:
|
|
Q4. Within the past 12 months have you been prescribed or taken any of the following:
|
|
Q5. Within the past 12 months have you been prescribed or taken medications for both diabetes and a heart condition? (Answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition. |
Q1. Within the past 12 months, and in relation only to the medical conditions listed below, have you:
Any of the following medical conditions:
|
|
Q2. Have you had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure)? | |
Q3. Within the past 12 months have you:
|
|
Q4. Within the past 12 months have you been prescribed or taken any of the following:
|
|
Q5. Within the past 12 months have you been prescribed or taken medications for both diabetes and a heart condition? (Answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition. |
Q1. Within the past 12 months, and in relation only to the medical conditions listed below, have you:
Any of the following medical conditions:
|
|
Q2. Have you had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure)? | |
Q3. Within the past 12 months have you:
|
|
Q4. Within the past 12 months have you been prescribed or taken any of the following:
|
|
Q5. Within the past 12 months have you been prescribed or taken medications for both diabetes and a heart condition? (Answer No if you are medicated for one but not both of these conditions. Medication prescribed solely for the control of blood pressure is not a medication for a heart condition. |