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Medical Declaration

All applicants of age 60 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:
Change in medication means the medication dosage, frequency or type has been reduced, increased, stopped and/or new medication(s) has/have been prescribed. Exceptions: the routine adjustment of Coumadin, Warfarin or insulin, as long as they are not newly prescribed or stopped and there has been no change in your medical condition; and, a change from a brand name medication to a generic brand medication of the same dosage
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:

  1. been treated for and/or been diagnosed with internal bleeding; or
  2. been admitted to hospital for a gastrointestinal disease or disorder; or
  3. received treatment including investigation or testing where the results indicate either a new diagnosis of cancer or that cancer has returned or spread (except basal cell and squamous cell skin cancer or breast cancer treated only with hormonal therapy)?

Q4. Within the past 12 months have you been prescribed or taken any of the following:

  1. prednisone for any lung condition; or
  2. any form of nitroglycerin for the relief of angina pain (including on an "as needed" basis)?

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:
Change in medication means the medication dosage, frequency or type has been reduced, increased, stopped and/or new medication(s) has/have been prescribed. Exceptions: the routine adjustment of Coumadin, Warfarin or insulin, as long as they are not newly prescribed or stopped and there has been no change in your medical condition; and, a change from a brand name medication to a generic brand medication of the same dosage
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:

  1. been treated for and/or been diagnosed with internal bleeding; or
  2. been admitted to hospital for a gastrointestinal disease or disorder; or
  3. received treatment including investigation or testing where the results indicate either a new diagnosis of cancer or that cancer has returned or spread (except basal cell and squamous cell skin cancer or breast cancer treated only with hormonal therapy)?

Q4. Within the past 12 months have you been prescribed or taken any of the following:

  1. prednisone for any lung condition; or
  2. any form of nitroglycerin for the relief of angina pain (including on an "as needed" basis)?

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:
Change in medication means the medication dosage, frequency or type has been reduced, increased, stopped and/or new medication(s) has/have been prescribed. Exceptions: the routine adjustment of Coumadin, Warfarin or insulin, as long as they are not newly prescribed or stopped and there has been no change in your medical condition; and, a change from a brand name medication to a generic brand medication of the same dosage
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:

  1. been treated for and/or been diagnosed with internal bleeding; or
  2. been admitted to hospital for a gastrointestinal disease or disorder; or
  3. received treatment including investigation or testing where the results indicate either a new diagnosis of cancer or that cancer has returned or spread (except basal cell and squamous cell skin cancer or breast cancer treated only with hormonal therapy)?

Q4. Within the past 12 months have you been prescribed or taken any of the following:

  1. prednisone for any lung condition; or
  2. any form of nitroglycerin for the relief of angina pain (including on an "as needed" basis)?

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:
Change in medication means the medication dosage, frequency or type has been reduced, increased, stopped and/or new medication(s) has/have been prescribed. Exceptions: the routine adjustment of Coumadin, Warfarin or insulin, as long as they are not newly prescribed or stopped and there has been no change in your medical condition; and, a change from a brand name medication to a generic brand medication of the same dosage
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:

  1. been treated for and/or been diagnosed with internal bleeding; or
  2. been admitted to hospital for a gastrointestinal disease or disorder; or
  3. received treatment including investigation or testing where the results indicate either a new diagnosis of cancer or that cancer has returned or spread (except basal cell and squamous cell skin cancer or breast cancer treated only with hormonal therapy)?

Q4. Within the past 12 months have you been prescribed or taken any of the following:

  1. prednisone for any lung condition; or
  2. any form of nitroglycerin for the relief of angina pain (including on an "as needed" basis)?

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:
Change in medication means the medication dosage, frequency or type has been reduced, increased, stopped and/or new medication(s) has/have been prescribed. Exceptions: the routine adjustment of Coumadin, Warfarin or insulin, as long as they are not newly prescribed or stopped and there has been no change in your medical condition; and, a change from a brand name medication to a generic brand medication of the same dosage
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:

  1. been treated for and/or been diagnosed with internal bleeding; or
  2. been admitted to hospital for a gastrointestinal disease or disorder; or
  3. received treatment including investigation or testing where the results indicate either a new diagnosis of cancer or that cancer has returned or spread (except basal cell and squamous cell skin cancer or breast cancer treated only with hormonal therapy)?

Q4. Within the past 12 months have you been prescribed or taken any of the following:

  1. prednisone for any lung condition; or
  2. any form of nitroglycerin for the relief of angina pain (including on an "as needed" basis)?

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.

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