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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

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
 
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?   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?   Yes No
 
8 In the last 24 months have you been diagnosed with or been treated by a Hematologist or an Internist for a blood disorder for a blood disorder?   Yes No
 
9 Have you smoked / used tobacco or tobacco products or vaped any nicotine products (including e-cigarettes) within the past ...  
 
  

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   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 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)  
 
  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?  
 
  

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 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
    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?
 
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?
 
b) In the past 12 months, have you had a change in your ongoing drug treatment for high blood pressure ? Yes No
 
6 MUSCLE, BONE AND JOINT DISORDER (definition) Yes No
 
a) Arthritis
 
b) Osteoporosis
 
c) Other conditions
 

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?
 
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) In the past 12 months, have you had a change in your ongoing cholesterol drug treatment ? Yes No
 
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, 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 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 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? Yes No
 
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

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