Medical Declaration
All applicants aged 40 or older with pre-existing medical conditions coverage requirement need to complete this medical declaration.
Please answer the following yes/no questions:
| Q1. In the past five (5) years, have you: | |
| a) been diagnosed and/or treated for Heart or Cardiovascular conditions? |
|
b) been diagnosed and/or treated with insulin for Diabetes? |
|
| c) been diagnosed and or treated for Kidney, Gastro-intestinal, Digestive or Liver conditions? | |
| Q2. In the past two (2) years, have you: | |
| a) been diagnosed and/or treated for any Lung condition? |
|
b) been prescribed to use oral steroid medication for a Lung condition? |
|
| Q3. In the past 12 months, have you: | |
| a) been diagnosed and/or treated for Low/High Blood Pressure with 2 or more pills a day? |
|
b) been diagnosed and/or treated with oral (pills) medication for Diabetes? |
|
| Q4. Have you been prescribed a total of six (6) or more separate and distinct prescription medications for your chronic conditions? |
| Q1. In the past five (5) years, have you: | |
| a) been diagnosed and/or treated for Heart or Cardiovascular conditions? |
|
b) been diagnosed and/or treated with insulin for Diabetes? |
|
| c) been diagnosed and or treated for Kidney, Gastro-intestinal, Digestive or Liver conditions? | |
| Q2. In the past two (2) years, have you: | |
| a) been diagnosed and/or treated for any Lung condition? |
|
b) been prescribed to use oral steroid medication for a Lung condition? |
|
| Q3. In the past 12 months, have you: | |
| a) been diagnosed and/or treated for Low/High Blood Pressure with 2 or more pills a day? |
|
b) been diagnosed and/or treated with oral (pills) medication for Diabetes? |
|
| Q4. Have you been prescribed a total of six (6) or more separate and distinct prescription medications for your chronic conditions? |
| Q1. In the past five (5) years, have you: | |
| a) been diagnosed and/or treated for Heart or Cardiovascular conditions? |
|
b) been diagnosed and/or treated with insulin for Diabetes? |
|
| c) been diagnosed and or treated for Kidney, Gastro-intestinal, Digestive or Liver conditions? | |
| Q2. In the past two (2) years, have you: | |
| a) been diagnosed and/or treated for any Lung condition? |
|
b) been prescribed to use oral steroid medication for a Lung condition? |
|
| Q3. In the past 12 months, have you: | |
| a) been diagnosed and/or treated for Low/High Blood Pressure with 2 or more pills a day? |
|
b) been diagnosed and/or treated with oral (pills) medication for Diabetes? |
|
| Q4. Have you been prescribed a total of six (6) or more separate and distinct prescription medications for your chronic conditions? |
| Q1. In the past five (5) years, have you: | |
| a) been diagnosed and/or treated for Heart or Cardiovascular conditions? |
|
b) been diagnosed and/or treated with insulin for Diabetes? |
|
| c) been diagnosed and or treated for Kidney, Gastro-intestinal, Digestive or Liver conditions? | |
| Q2. In the past two (2) years, have you: | |
| a) been diagnosed and/or treated for any Lung condition? |
|
b) been prescribed to use oral steroid medication for a Lung condition? |
|
| Q3. In the past 12 months, have you: | |
| a) been diagnosed and/or treated for Low/High Blood Pressure with 2 or more pills a day? |
|
b) been diagnosed and/or treated with oral (pills) medication for Diabetes? |
|
| Q4. Have you been prescribed a total of six (6) or more separate and distinct prescription medications for your chronic conditions? |
| Q1. In the past five (5) years, have you: | |
| a) been diagnosed and/or treated for Heart or Cardiovascular conditions? |
|
b) been diagnosed and/or treated with insulin for Diabetes? |
|
| c) been diagnosed and or treated for Kidney, Gastro-intestinal, Digestive or Liver conditions? | |
| Q2. In the past two (2) years, have you: | |
| a) been diagnosed and/or treated for any Lung condition? |
|
b) been prescribed to use oral steroid medication for a Lung condition? |
|
| Q3. In the past 12 months, have you: | |
| a) been diagnosed and/or treated for Low/High Blood Pressure with 2 or more pills a day? |
|
b) been diagnosed and/or treated with oral (pills) medication for Diabetes? |
|
| Q4. Have you been prescribed a total of six (6) or more separate and distinct prescription medications for your chronic conditions? |
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