Medical Questionaire
Q1. Have you been advised against travel by a physician?
Q2. Do you have a surgically untreated aneurysm?
Q3. Do you have or have you ever had:
- Pancreatic or liver cancer, or any type of metastasized cancer
- A kidney condition requiring dialysis
- Congestive Heart Failure
- A Bone Marrow or Organ Transplant
- A Terminal Sickness
Q4. Do you currently reside in a nursing home, assisted living home, convalescent home, hospice or rehabilitation centre?
Q5. Do you require assistance with normal daily activities?
Q6. Have you taken (or been prescribed) oral steroids, or used home oxygen to treat a lung condition in the 12 months before your start date?
Q7. Please check each condition you have been diagnosed with or treated for in the 12 months before your start date:
| Coronary Artery Disease, (including heart attack or angina) | |
| Valvular heart disease (including stenosis, regurgitation or valve replacement) | |
| Heart arrhythmia (including atrial flutter, atrial fibrillation, ventricular fibrillation or use of a pacemaker) | |
| A lung or respiratory condition for which daily medication has been prescribed (including inhalers) | |
| Diabetes requiring insulin | |
| Stroke or mini-stroke (TIA) | |
| Aneurysm | |
| Blood clots | |
| Gastro-intestinal bleed |
| Coronary Artery Disease, (including heart attack or angina) | |
| Valvular heart disease (including stenosis, regurgitation or valve replacement) | |
| Heart arrhythmia (including atrial flutter, atrial fibrillation, ventricular fibrillation or use of a pacemaker) | |
| A lung or respiratory condition for which daily medication has been prescribed (including inhalers) | |
| Diabetes requiring insulin | |
| Stroke or mini-stroke (TIA) | |
| Aneurysm | |
| Blood clots | |
| Gastro-intestinal bleed |
| Coronary Artery Disease, (including heart attack or angina) | |
| Valvular heart disease (including stenosis, regurgitation or valve replacement) | |
| Heart arrhythmia (including atrial flutter, atrial fibrillation, ventricular fibrillation or use of a pacemaker) | |
| A lung or respiratory condition for which daily medication has been prescribed (including inhalers) | |
| Diabetes requiring insulin | |
| Stroke or mini-stroke (TIA) | |
| Aneurysm | |
| Blood clots | |
| Gastro-intestinal bleed |
| Coronary Artery Disease, (including heart attack or angina) | |
| Valvular heart disease (including stenosis, regurgitation or valve replacement) | |
| Heart arrhythmia (including atrial flutter, atrial fibrillation, ventricular fibrillation or use of a pacemaker) | |
| A lung or respiratory condition for which daily medication has been prescribed (including inhalers) | |
| Diabetes requiring insulin | |
| Stroke or mini-stroke (TIA) | |
| Aneurysm | |
| Blood clots | |
| Gastro-intestinal bleed |
| Coronary Artery Disease, (including heart attack or angina) | |
| Valvular heart disease (including stenosis, regurgitation or valve replacement) | |
| Heart arrhythmia (including atrial flutter, atrial fibrillation, ventricular fibrillation or use of a pacemaker) | |
| A lung or respiratory condition for which daily medication has been prescribed (including inhalers) | |
| Diabetes requiring insulin | |
| Stroke or mini-stroke (TIA) | |
| Aneurysm | |
| Blood clots | |
| Gastro-intestinal bleed |
Q8. Were you admitted to the hospital for the following condition(s) in the 12 months before your start date?
Declaration