TNinsurance.ca 1-877-443-0101 Contact Us

Travel Medical Insurance for Canadians

Travel Medical Questionnaire

  • This is a generalized questionnaire that contains questions from the 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 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

 

          Travel Destination:   


Select your trip plan:
Single Trip Annual Multi-Trip Top-Up Annual Multi-Trip + Top-Up


Total Number of Days: 
Number of Days per Trip:  
Total Trip Duration: Number of days covered under your existing policy:
Multi-Trip plan: Number of days per trip:    Your longest trip duration:   


Would you like to provide more information about your trip?     No Yes
Copyright Ⓒ 2018-2025 TNinsurance.ca

Travel Medical Questionnaire:

Section 1

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
 
  Have you received or recommended any bone marrow, stem cell, or organ transplant (excluding skin or cornea)  in the two (2) years before the effective date?   Yes No
4 Have you been prescribed or used home oxygen in the last 24 months?   Yes No
 
  When was the last time you used or were prescribed home oxygen?  
5 Do you require assistance with any activities of daily living?   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 required dialysis in the last 24 months?   Yes No
 
  When was the last time a dialysis procedure was performed or required?  
 
8 In the last 24 months have you been diagnosed with or been treated by a Hematologist or an Internist for a blood disorder?   Yes No
 
9 Have you smoked / used tobacco or tobacco products or vaped any nicotine products (including e-cigarettes) in the last 24 months?   Yes No
 
  When was the last time you smoked or used any tobacco or nicotine products (including e-cigarettes)?  
 
  
Copyright Ⓒ 2018-2025 TNinsurance.ca

Travel Medical Questionnaire:

Section 2

Have you EVER received a Diagnosis, a Treatment 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.


 

1   HEART CONDITION: Pacemaker / Defibrillator, Heart Rhythm Disorder (including but not limited: tachycardia, ventricular tachycardia, bradycardia, atrial fibrillation, extrasystole, atrial flutter, bundle branch block), Bypass, Angioplasty, Stent, Valvular Surgery, Angina (Chest Pain), Infarction (Heart Attack), Heart valve disease not surgically treated, Heart Failure (CHF), Cardiomyopathy or myocarditis, Pulmonary Edema, Coronary Artery Disease (CAD) or other heart conditions not mentioned above   Yes No
  
    How many medications are currently prescribed for heart condition/disease?
Do not include ASPIRIN
 
  a) Do you have a Pacemaker / Defibrillator?  
    When was your last visit to Pacemaker clinic?  
 
  b) Heart Rhythm Disorder (including but not limited: tachycardia, ventricular tachycardia, bradycardia, atrial fibrillation, extrasystole, atrial flutter, bundle branch block)  
    Do you have an atrial fibrillation or other disorder?  
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 the procedure performed (date of the most recent procedure)?  
    Since your last procedure, 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)  
    If YES, when did it happen?  
  f) Heart valve disease not surgically treated  
    What is the stage of your valvular disease?  
   

Have you experienced any of the following Symptoms in the last 12 months: shortness of breath, dizziness or fainting, chest pain, palpitations, weakness or fatigue, swelling of the feet, ankles or abdomen?

   Yes No
 
  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 water pills for heart failure, ankle or leg swelling, or water on the lungs in the last 2 years?  
 
  h) Cardiomyopathy or myocarditis  
    Have you taken or been prescribed medication, been treated for this condition?  
    Have you been prescribed or taken water pills for heart failure, ankle or leg swelling, or water on the lungs in the last 2 years?  
 
  i) Pulmonary Edema  
    Have you been prescribed or taken water pills for heart failure, ankle or leg swelling, or water on the lungs in the last 2 years?  
 
  j) Coronary Artery Disease (CAD)  
 
  k) 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: Thrombosis, Phlebitis, Blood clots, Pulmonary Embolism, Aneurysm (Abdominal, Thoracic or Cerebral), Dilatation of the aorta, Leg Stenosis, Blockage (Partial or Complete), Carotid Stenosis / Blockage (Neck Artery), Arteriosclerosis and/or atherosclerosis also known as hardening of the arteries   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) Any Aneurysm / 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?  
 
  e) Arteriosclerosis and/or atherosclerosis also known as hardening of the arteries  
 
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)  
 
    How many medications including aspirin are currently prescribed for Stroke / Mini-Stroke, CVA or TIA conditions?  
 
4   NEUROLOGICAL DISORDER: Parkinson's disease, Alzheimer's Disease/Cognitive Disorder, Multiple Sclerosis, Epilepsy, Seizures / Syncope or other neurological disorders   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: Chronic Obstructive Pulmonary Disease(COPD), Pulmonary Fibrosis, Pulmonary Embolism, Bronchitis and Chronic Bronchitis, Emphysema, Asthma, Pneumonia or Other Chronic Lung Conditions   Yes No
 
a) Have you been been diagnosed with, treated and/or prescribed medication for your lung condition in the last ...
 
b) How many medications (including inhalers, puffers and home oxygen) are currently prescribed for Lung conditions (excluding asthma and/or seasonal allergies)?
 
  c) Chronic Obstructive Pulmonary Disease(COPD) / Pulmonary Fibrosis / Chronic Bronchitis / Emphysema / Pulmonary Embolism / Asthma (including inhalers for allergies) / Other Chronic Lung Conditions  
    Have you been hospitalized or treated in ER for this condition In the past 24 months?  
    Number of hospitalizations or visits to ER for this condition in the last 12 months?  
 
  d) Pneumonia / Bronchitis in the last 2 years?   Yes No
    Have you had pneumonia in the last 12 months?    Yes No
    Number of hospitalizations or visits to ER due to pneumonia in the last 12 months?  
   

Have you had two or more bronchitis episodes in the last 12 months?

   Yes No
 
  e) Have you had a Change related to Lung condition in the 12 months preceding your policy effective date?  
 
  f) Have you been prescribed or used home oxygen for your lung condition?
  
 
  g) Have you been prescribed or taken 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 had lung cancer, pancreatic cancer, liver cancer, bone cancer?  
 
  c) Have you had cancer or received chemotherapy and/or radiotherapy and/or other treatment (including medications), other than routine follow-up for cancer?
Do not declare basal cell and squamous cell skin cancer and breast cancer treated only with hormonal therapy within the time period in question 		 
 
  d) Have you had chemotherapy, immunotherapy, or targeted therapy in the 12 months before your Application Date?   Yes No
 
  e) Have you had chemotherapy of any form (except cream) within 6 months before Departure date?   Yes No
 
  f) In the 3 months before Departure, have you had any cancer treatment?
(other than for basal or squamous cell skin cancer or breast cancer treated only with hormone therapy)		   Yes No
7   Have you ever had pulmonary hypertension?
(A condition of increased blood pressure within the arteries of the lungs) 		  Yes No
  
Copyright Ⓒ 2018-2025 TNinsurance.ca

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:

 

1 DIGESTIVE TRACT DISORDERS: Diverticulitis, Bowel Obstruction, Inflammatory Bowel Disease, Ulcer, Crohn's Disease, Ulcerative Colitis, Peptic Ulcer, Gastrointestinal bleeding, GERD (gastro-esophageal reflux disease), Chronic intestinal disorders (including a stoma) and Other digestive tract disorders Yes No
 
a) Diverticulitis
    Referring to your Effective Date, when was your last 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) Inflammatory Bowel Disease
 
k) Other digestive tract disorders not mentioned above
 
2 INTERNAL DISORDERS: Liver disorder, Pancreatitis, Gallstones, Abdominal or Intestinal surgery, Kidney stone, Kidney infections, Kidney Disorder, Kidney Dialysis, Kidney Failure, Prostate disorder, Urinary disorder or infections, Spleen disease 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))
    Referring to your Effective Date, when was your last surgery?  
 
e) Kidney Stone / Urinary Calculus
 
f) Kidney Infections
 
g) Kidney Disorders
    In the last 12 months, have you had Kidney disease requiring dialysis?  
 
h) Renal (Kidney) Failure followed by a specialist
 
i) Prostate Disorders (Enlarged prostate, Prostatitis)
 
j) Urinary disorder
    In the last 12 months, have you had two or more bladder infections?  
 
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?
    When did your doctor change the dosage of your medication (increase, decrease, stopping), or prescribe a new medication for diabetes last time?
Insulin adjustment is not considered a change. 		 
 
5 HIGH BLOOD PRESSURE (prescribed medications and treatment) Yes No
 
a) How many medications for high blood pressure have you been prescribed or taken in the last 12 months?
 
b) When did your doctor change the dosage of your medication (increase, decrease, stopping), or prescribe a new medication for high blood pressure last time?
 
6 MUSCLE, BONE AND JOINT DISORDER (definition) Yes No
 
a) Arthritis
 
b) Osteoporosis
 
c) Other conditions
 
7   HYPERTHYROIDISM / HYPOTHYROIDISM
 
Copyright Ⓒ 2018-2025 TNinsurance.ca

Travel Medical Questionnaire:

Section 4

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?
 
b) If YES, when did it happen?
 
c) When are you planning to start your trip?
 
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
 
a) When did your doctor change the dosage of your medication (increase, decrease, stopping), or prescribe a new cholesterol medication last time?
 
4 In the last SIX (6) months: Have you had any cardiac tests, other than routine tests? OR Have you had a loss of consciousness? Answer YES if either one of these situations applies to you. Yes No
 
5

How many medications in total, are you prescribed and currently take, including “as needed” Medication, inhalers, and Aspirin ?

(Do not count creams, supplements, and vitamins)
 
a) In the past 6 months have you been prescribed, refilled or taken prescription medication for prevention of a blood clot (blood thinner)?
E.g. Heparin, Warfarin / Coumadin.
 
6 When was the last time you had a Change 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)
 
a) When are you planning to start your trip?
 
7 Following a Change 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?
 
9 In the past 12 months, did you consult a doctor because of a fall?
 
old Have You ever been tested positive to COVID-19? Yes No
 
  a) Were You hospitalized? Yes No
 
  b) Do You still have aftereffects from COVID-19?
(Examples: Muscle or joint pain, shortness of breath, fatigue, headaches, loss of sense of smell and/or taste, others) 		Yes No
 
10 Have You been vaccinated, or will You be vaccinated for COVID-19 with vaccines approved in Canada at least 2 weeks before Your Departure Date?
 
10 In order to establish the premium, your height and weight may be needed (use metric or imperial system)   Height  cm;  f in
Weight kg;   lb
 

Notes

(If you want an insurance broker call you, please enter your phone number)

 

 

Your E-mail:

 

Please confirm:

 

Please confirm you are not a Robot or AI: