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:
A. Within the past 12 months, and in relation only to the medical conditions listed below, have you:
- been newly diagnosed with;
- been prescribed any new medication or any change in medication for;
- had any new or change in treatment, including investigation or testing (do not count regular scheduled maintenance investigations or testing);
- been referred to a specialist for; or
- been hospitalized or seen in the emergency department of a hospital for:
Any of the following medical conditions: (a) a heart condition (b) a lung condition (c) shortness of breath (d) chest pain (e) stroke, or mini-stroke or TIA (Transient Ischemic Attack)?
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B. Have you had a heart bypass, heart valve surgery or angioplasty more than 10 years ago (use the date of the most recent procedure)?
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C. Within the past 12 months have you:
- been treated for and/or been diagnosed with internal bleeding; or
- been admitted to hospital for a gastrointestinal disease or disorder; or
- 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)?
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D. Within the past 12 months have you been prescribed or taken any of the following:
- prednisone for any lung condition; or
- any form of nitroglycerin for the relief of angina pain (including on an “as needed” basis)?
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E. 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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