Travel Medical Questionnaire

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Travel Medical Insurance for Canadians

Travel Medical Questionnaire:

This is a generalized questionnaire that contains questions from medical questionnaires with various travel insurance providers.
The purpose of this questionnaire is to choose the option best suited to your insurance needs.
When the best plan is chosen, your final premium will be based on your answers to the insurer's medical questionnaire should one be required to purchase your insurance.

Who can apply:

TO BE ELIGIBLE FOR INSURANCE UNDER THIS POLICY, you must be eligible for benefits under your Provincial Government Health Insurance Plan for the entire trip duration.

Applicant and Trip Information:

Applicant Name:

Age:

Province of Residence

	- Single-Trip Medical Plan	- Annual Multi-Trip Medical Plan^*	Total Number of Days per Trip:
* For Annual Multi-trip plans, please choose 4, 8, 10, 15, 16, 18, 20, 30, 35, 60 days per trip
* * If you are topping-up your existing policy, please provide the details in section Notes below

Travel Medical Questionnaire:

Section 1

Travel Medical Questionnaire:

Section 2

Have you EVER received a Diagnosis, a , or have you been prescribed Medication * (including prescribed "as needed" medication, inhalers and aspirin) for any of the following conditions?

* Note that preventive Medication is considered a Treatment.

Travel Medical Questionnaire:

Section 3

During the 24 months prior to your application date, have you been diagnosed with, received treatment for, or been prescribed medication for any of the following medical conditions:

Travel Medical Questionnaire:

Section 4

Notes

(Please enter your phone number, if you want an insurance broker call you)

Your E-mail:

1	Have you been advised by a physician not to travel at this time?	Yes	No

2	Have you been diagnosed with a terminal condition?	Yes	No

3	Have you had a bone marrow or major organ transplant (heart, lung, liver, kidney or pancreas)?	Yes	No

4	Have you been prescribed home oxygen in the last twelve ( 12 ) months?	Yes	No

5	Do you require assistance with any activities of daily living? Activities of daily living means any of the following: eating, bathing, using the toilet, changing positions (including getting in and out of a bed or chair),dressing.	Yes	No

6	Do you require the use of a wheelchair or walker for your mobility? Please note that occasional use in airports or shopping centres is not considered	Yes	No

7	Have you ever been diagnosed with an auto-immune disorder ? Auto-immune disorder includes acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV), Grave’s disease, Lou Gehrig’s disease, myasthenia gravis, sarcoidosis any location, scleroderma, systematic lupus erythematosis.	Yes	No

8	In the last 24 months have you been diagnosed with or been treated Treated - Any medical, therapeutic or diagnostic procedure prescribed, performed or recommended by a Physician, including monitoring of specific issues following abnormal test results and/or changes in health condition, prescribed Medications (including Medication prescribed ”as needed”), investigative tests and surgery. by a Hematologist or an Internist for a blood disorder for a blood disorder?	Yes	No

9	Have you smoked tobacco or used tobacco products within the past ...

1		HEART CONDITION	Yes	No

	a)	How many medications are currently prescribed for heart condition/disease? Do not include aspirin, hypertension (high blood pressure) and high cholesterol medication)

	b)	Heart Rhythm Disorder
		Do you require a Pacemaker / Defibrillator?
		In the 24 months preceding your Effective Date, have you been prescribed or renewed Medication for this condition (including aspirin, blood thinner and Medication that was prescribed "as needed")?

	c)	Bypass / Angioplasty / Stent / Valvular Surgery
		When was your Surgery performed (date of the most recent surgery)?
		Since your last surgery, have you used Nitroglycerin that was prescribed "as needed"?

	d)	Angina (Chest Pain) Declaration is no longer needed if ALL stenoses / blockages have been treated by angioplasty / stent/bypass.
		When did you use Nitroglycerin that was prescribed "as needed" for the last time?

	e)	Infarction (Heart Attack)

	f)	Heart valve disease not surgically treated

	g)	Heart Failure (CHF)
		Have you taken or been prescribed medication, been treated for this condition in the last ...
		Have you been prescribed or taken Lasix or Furosemide or a water pill for heart failure, ankle or leg swelling, or water on the lungs in the last 2 years?

	h)	Cardiomyopathy
		Have you taken or been prescribed medication, been treated for this condition?
		Have you been prescribed or taken Lasix or Furosemide or a water pill for heart failure, ankle or leg swelling, or water on the lungs in the last 2 years?

	i)	Pulmonary Edema (water on the lungs)
		Have you been prescribed or taken Lasix or Furosemide or a water pill for heart failure, ankle or leg swelling, or water on the lungs in the last 2 years?

	j)	Other heart conditions not mentioned above
		When was the last time you was prescribed and/or took medications (including aspirin and cholesterol medications) or received other treatment for this condition ?

2		VASCULAR CONDITION	Yes	No

	a)	Thrombosis / Phlebitis / Blood clots / Pulmonary Embolism
		Except Aspirin, have you had any Treatment or been prescribed Medication for this condition in the last 24 months?

	b)	Aneurysm (Abdominal, Thoracic or Cerebral) / Dilatation of the aorta /
		Treated by surgery / Size?

	c)	Leg Stenosis / Blockage (Partial or Complete)
		Do you feel pain when walking or do you suffer from claudication (limping)?

	d)	Carotid Stenosis / Blockage (Neck Artery)
		Surgically treated?

3		STROKE / Cerebro-Vascular Accident (CVA) / Transient Ischemic Attack (TIA) / Mini-Stroke	Yes	No

	a)	When was your last CVA and/or TIA?

	b)	When was the last time you took or were prescribed medications, received treatment, or were followed by a specialist for the above condition? (Including prescribed "as needed" medication, and aspirin prescribed or recommended by your doctor)

4		NEUROLOGICAL DISORDER	Yes	No

	a)	Parkinson's disease
		How many times have you fallen within the last 12 months?
		How many times have you suffered from pneumonia within the last 12 months?

	b)	Alzheimer's Disease/Cognitive Disorder
		How many times have you fallen within the last 12 months?
		How many times have you suffered from pneumonia within the last 12 months?

	c)	Other neurological disorders
		Please choose

5		LUNG CONDITION	Yes	No

	a)	How many medications (including inhalers) are currently prescribed for Lung conditions (including asthma)?

	b)	Chronic Obstructive Pulmonary Disease(COPD) / Pulmonary Fibrosis / Chronic Bronchitis / Emphysema / Asthma (including inhalers for allergies)
		Number of hospitalizations or visits to ER in the last 12 month?

	c)	Asthma if you have a prescription for inhalers for seasonal allergies only

	d)	Pneumonia / Bronchitis
		Number of hospitalizations or visits to ER in the last 12 months?

	e)	Have you been prescribed or used home oxygen and/or oral steroids (e.g. prednisone) for your lung condition? Oral steroids are steroids that are swallowed to treat a lung condition. They do not include steroids that are inhaled

6		CANCER	Yes	No

	a)	Have you ever been diagnosed with metastatic cancer ? "Metastatic" means that the cancer has spread to lymph nodes (positive nodes) or to other organs (distant metastasis).

	b)	Have you ever been diagnosed with stage 3 or 4 cancer?

	c)	Have you ever had lung cancer, pancreatic cancer, liver cancer?

	d)	Have you had cancer or received chemotherapy and/or radiotherapy and/or other treatment (including medications), other than routine follow-up for cancer in the last ... Do not declare basal cell and squamous cell skin cancer and breast cancer treated only with hormonal therapy within the time period in question

	e)	Within 3 months before departure date, have you received any treatment for any cancer?

	f)	Have you had intravenous chemotherapy within 3 months before departure date?

1		DIGESTIVE TRACT DISORDERS	Yes	No

	a)	Diverticulitis

	b)	Bowel Obstruction / Partial Bowel Obstruction

	c)	Ulcer

	d)	Crohn's Disease

	e)	Ulcerative Colitis

	f)	Peptic Ulcer

	g)	Gastrointestinal bleeding

	h)	GERD (gastro-esophageal reflux disease)

	i)	Chronic intestinal disorders (including a stoma)

	j)	Other digestive tract disorders not mentioned above

2		INTERNAL DISORDERS	Yes	No

	a)	Liver disease

	b)	Pancreatitis

	c)	Existing Biliary Calculus (Gallstone)

	d)	Abdominal or Intestinal surgery (excluding hernia surgery, hemorrhoids surgery and gallbladder removal (cholecystectomy))

	e)	Kidney Stone / Urinary Calculus

	f)	Kidney Infections

	g)	Kidney Disorders

	h)	Renal (Kidney) Failure

	i)	Prostate Disorders

	j)	Urinary disorder

	k)	Spleen disease

3		FIBROMYALGIA	Yes	No

4		DIABETES (controlled by medication, or diet, or glucose intolerance / pre-diabetes.)	Yes	No

	a)	Treatment:

	b)	How many medication are currently prescribed for diabetes?

	c)	Have you been treated for diabetes in the last 12 months?

5		HIGH BLOOD PRESSURE	Yes	No

	a)	How many medications for high blood pressure have you been prescribed or taken in the last 12 months?

6		MUSCLE, BONE AND JOINT DISORDER (definition) Muscle, bone and joint disorder includes degenerative disc disease (DDD), herniated disc,osteoporosis, osteopenia, rheumatoid arthritis, sciatica, scoliosis, spinalstenosis, spondylitis/spondylosis.

1		In the last TWELVE (12) months, for any condition, have you been hospitalized, surgically treated or treated in any ER?	Yes	No

	a)	If YES, for what condition?

2		In the last twelve (12) months, have you had investigative testing or treatment for shortness of breath or chest pain?	Yes	No

3		In the last twelve (12) months, have you been prescribed cholesterol medications?	Yes	No

4		In the last SIX (6) months: (Answer YES if either one of these situations applies to you.)Have you had any cardiac tests, other than routine tests? OR Have you had a loss of consciousness?	Yes	No

5		How many medications, including “as needed” Medication, inhalers and Aspirin are currently prescribed? (Do not count : creams, drops and vitamins)

6		When was the last time you had a Change Change - Means any of the following alteration or deterioration of Your health status: a) onset of new and/or more frequent Symptoms; or b) You have received a new diagnosis; or c) You have been hospitalized, or other than routine, You have sought consultation from a Physician, You have undergone examinations or tests for the purpose of establishing a diagnosis; or d) Your Treatment has been modified; You have been prescribed a new Medication and/or a Medication has been stopped and/or the dosage and/or the frequency of an existing Medication has increased or decreased. (Exceptions the routine adjustment of Coumadin, Warfarin or insulin and the change from a brand name Medication to a generic brand Medication of the same dosage). to your Health OR a physician stopped or increased/decreased a dosage of your medications, prescribed a new medication? (Including prescribed "as needed" medication, inhalers and aspirin)

7		Following a Change Change - Means any of the following alteration or deterioration of Your health status: a) onset of new and/or more frequent Symptoms; or b) You have received a new diagnosis; or c) You have been hospitalized, or other than routine, You have sought consultation from a Physician, You have undergone examinations or tests for the purpose of establishing a diagnosis; or d) Your Treatment has been modified; You have been prescribed a new Medication and/or a Medication has been stopped and/or the dosage and/or the frequency of an existing Medication has increased or decreased. (Exceptions the routine adjustment of Coumadin, Warfarin or insulin and the change from a brand name Medication to a generic brand Medication of the same dosage). in your health, are you in the process of being investigated or awaiting a diagnosis or Treatment?	Yes	No

8		When did you have your last check up?