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Medical Declaration

Applicants of age 60 and above needs to fill the medical questionnaire below. Please answer the following yes/no questions.

Eligibility – Medical Questionnaire (1 of 2)

Q1. Are you travelling against the advice of a physician?
Q2. Have you ever had or are you awaiting a bone marrow, stem cell, or organ transplant (excluding corneal transplant)?

Q3. Within the past 24 months, have you:

  1. used or been prescribed home oxygen, or Lasix or furosemide for any reason?
  2. required kidney dialysis?
  3. been newly diagnosed with, or experienced a change in symptoms, a change in treatment or a change in prescription medication for: stroke, T.I.A. (transient ischemic attack), heart condition, blocked or narrowed arteries in the legs (peripheral vascular disease), diabetes treated with medication and/or insulin, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or metastatic cancer?

Q4. Have you had heart bypass surgery, angioplasty or heart valve surgery more than 10 years ago?

Q1. Are you travelling against the advice of a physician?
Q2. Have you ever had or are you awaiting a bone marrow, stem cell, or organ transplant (excluding corneal transplant)?

Q3. Within the past 24 months, have you:

  1. used or been prescribed home oxygen, or Lasix or furosemide for any reason?
  2. required kidney dialysis?
  3. been newly diagnosed with, or experienced a change in symptoms, a change in treatment or a change in prescription medication for: stroke, T.I.A. (transient ischemic attack), heart condition, blocked or narrowed arteries in the legs (peripheral vascular disease), diabetes treated with medication and/or insulin, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or metastatic cancer?

Q4. Have you had heart bypass surgery, angioplasty or heart valve surgery more than 10 years ago?

Q1. Are you travelling against the advice of a physician?
Q2. Have you ever had or are you awaiting a bone marrow, stem cell, or organ transplant (excluding corneal transplant)?

Q3. Within the past 24 months, have you:

  1. used or been prescribed home oxygen, or Lasix or furosemide for any reason?
  2. required kidney dialysis?
  3. been newly diagnosed with, or experienced a change in symptoms, a change in treatment or a change in prescription medication for: stroke, T.I.A. (transient ischemic attack), heart condition, blocked or narrowed arteries in the legs (peripheral vascular disease), diabetes treated with medication and/or insulin, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or metastatic cancer?

Q4. Have you had heart bypass surgery, angioplasty or heart valve surgery more than 10 years ago?

Q1. Are you travelling against the advice of a physician?
Q2. Have you ever had or are you awaiting a bone marrow, stem cell, or organ transplant (excluding corneal transplant)?

Q3. Within the past 24 months, have you:

  1. used or been prescribed home oxygen, or Lasix or furosemide for any reason?
  2. required kidney dialysis?
  3. been newly diagnosed with, or experienced a change in symptoms, a change in treatment or a change in prescription medication for: stroke, T.I.A. (transient ischemic attack), heart condition, blocked or narrowed arteries in the legs (peripheral vascular disease), diabetes treated with medication and/or insulin, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or metastatic cancer?

Q4. Have you had heart bypass surgery, angioplasty or heart valve surgery more than 10 years ago?

Q1. Are you travelling against the advice of a physician?
Q2. Have you ever had or are you awaiting a bone marrow, stem cell, or organ transplant (excluding corneal transplant)?

Q3. Within the past 24 months, have you:

  1. used or been prescribed home oxygen, or Lasix or furosemide for any reason?
  2. required kidney dialysis?
  3. been newly diagnosed with, or experienced a change in symptoms, a change in treatment or a change in prescription medication for: stroke, T.I.A. (transient ischemic attack), heart condition, blocked or narrowed arteries in the legs (peripheral vascular disease), diabetes treated with medication and/or insulin, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or metastatic cancer?

Q4. Have you had heart bypass surgery, angioplasty or heart valve surgery more than 10 years ago?

Premium Rate Identification – Medical Questionnaire (2 of 2)

Q5. In the last 10 years, have you been diagnosed with or had an investigation, medical consultation, been prescribed medication or received treatment for a heart condition or had a pacemaker or defibrillator implant, stent placement, ablation or valve surgery?
Q6. Within the past 24 months, have you been diagnosed with, and/or had treatment and/or been hospitalized (as an in-patient or seen in the emergency department), and/or been prescribed or taken medication for any of the following conditions:
  1. Stroke or T.I.A. (transient ischemic attack), or Syncope (fainting spells)?
  2. Narrowing or blockage of any arteries; or aneurysm?
  3. Chronic obstructive pulmonary disease, chronic bronchitis or emphysema?
  4. Cancer (excluding basal or squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?
  5. Diabetes (treated with medication and/or insulin)?
  6. Alzheimer’s disease or any other form of dementia, Parkinson’s disease or multiple sclerosis?
  7. Chronic bowel disorder, bowel obstruction or surgery, gastrointestinal bleeding, diverticular disorder requiring prescription medication or surgery, or pancreatic disorder?
  8. Kidney disorders, hepatitis or cirrhosis of the liver?

Q7. Within the past 12 months, have you been newly diagnosed with, or experienced a change in symptoms or a change in prescription medication for high blood pressure or asthma?

Q5. In the last 10 years, have you been diagnosed with or had an investigation, medical consultation, been prescribed medication or received treatment for a heart condition or had a pacemaker or defibrillator implant, stent placement, ablation or valve surgery?
Q6. Within the past 24 months, have you been diagnosed with, and/or had treatment and/or been hospitalized (as an in-patient or seen in the emergency department), and/or been prescribed or taken medication for any of the following conditions:
  1. Stroke or T.I.A. (transient ischemic attack), or Syncope (fainting spells)?
  2. Narrowing or blockage of any arteries; or aneurysm?
  3. Chronic obstructive pulmonary disease, chronic bronchitis or emphysema?
  4. Cancer (excluding basal or squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?
  5. Diabetes (treated with medication and/or insulin)?
  6. Alzheimer’s disease or any other form of dementia, Parkinson’s disease or multiple sclerosis?
  7. Chronic bowel disorder, bowel obstruction or surgery, gastrointestinal bleeding, diverticular disorder requiring prescription medication or surgery, or pancreatic disorder?
  8. Kidney disorders, hepatitis or cirrhosis of the liver?

Q7. Within the past 12 months, have you been newly diagnosed with, or experienced a change in symptoms or a change in prescription medication for high blood pressure or asthma?

Q5. In the last 10 years, have you been diagnosed with or had an investigation, medical consultation, been prescribed medication or received treatment for a heart condition or had a pacemaker or defibrillator implant, stent placement, ablation or valve surgery?
Q6. Within the past 24 months, have you been diagnosed with, and/or had treatment and/or been hospitalized (as an in-patient or seen in the emergency department), and/or been prescribed or taken medication for any of the following conditions:
  1. Stroke or T.I.A. (transient ischemic attack), or Syncope (fainting spells)?
  2. Narrowing or blockage of any arteries; or aneurysm?
  3. Chronic obstructive pulmonary disease, chronic bronchitis or emphysema?
  4. Cancer (excluding basal or squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?
  5. Diabetes (treated with medication and/or insulin)?
  6. Alzheimer’s disease or any other form of dementia, Parkinson’s disease or multiple sclerosis?
  7. Chronic bowel disorder, bowel obstruction or surgery, gastrointestinal bleeding, diverticular disorder requiring prescription medication or surgery, or pancreatic disorder?
  8. Kidney disorders, hepatitis or cirrhosis of the liver?

Q7. Within the past 12 months, have you been newly diagnosed with, or experienced a change in symptoms or a change in prescription medication for high blood pressure or asthma?

Q5. In the last 10 years, have you been diagnosed with or had an investigation, medical consultation, been prescribed medication or received treatment for a heart condition or had a pacemaker or defibrillator implant, stent placement, ablation or valve surgery?
Q6. Within the past 24 months, have you been diagnosed with, and/or had treatment and/or been hospitalized (as an in-patient or seen in the emergency department), and/or been prescribed or taken medication for any of the following conditions:
  1. Stroke or T.I.A. (transient ischemic attack), or Syncope (fainting spells)?
  2. Narrowing or blockage of any arteries; or aneurysm?
  3. Chronic obstructive pulmonary disease, chronic bronchitis or emphysema?
  4. Cancer (excluding basal or squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?
  5. Diabetes (treated with medication and/or insulin)?
  6. Alzheimer’s disease or any other form of dementia, Parkinson’s disease or multiple sclerosis?
  7. Chronic bowel disorder, bowel obstruction or surgery, gastrointestinal bleeding, diverticular disorder requiring prescription medication or surgery, or pancreatic disorder?
  8. Kidney disorders, hepatitis or cirrhosis of the liver?

Q7. Within the past 12 months, have you been newly diagnosed with, or experienced a change in symptoms or a change in prescription medication for high blood pressure or asthma?

Q5. In the last 10 years, have you been diagnosed with or had an investigation, medical consultation, been prescribed medication or received treatment for a heart condition or had a pacemaker or defibrillator implant, stent placement, ablation or valve surgery?
Q6. Within the past 24 months, have you been diagnosed with, and/or had treatment and/or been hospitalized (as an in-patient or seen in the emergency department), and/or been prescribed or taken medication for any of the following conditions:
  1. Stroke or T.I.A. (transient ischemic attack), or Syncope (fainting spells)?
  2. Narrowing or blockage of any arteries; or aneurysm?
  3. Chronic obstructive pulmonary disease, chronic bronchitis or emphysema?
  4. Cancer (excluding basal or squamous cell skin cancer, and breast cancer treated only with hormonal therapy)?
  5. Diabetes (treated with medication and/or insulin)?
  6. Alzheimer’s disease or any other form of dementia, Parkinson’s disease or multiple sclerosis?
  7. Chronic bowel disorder, bowel obstruction or surgery, gastrointestinal bleeding, diverticular disorder requiring prescription medication or surgery, or pancreatic disorder?
  8. Kidney disorders, hepatitis or cirrhosis of the liver?

Q7. Within the past 12 months, have you been newly diagnosed with, or experienced a change in symptoms or a change in prescription medication for high blood pressure or asthma?