HMC Visitors to Canada Insurancce Medical Questionnaire

Applicant Information

Name of Applicant:
Age of Applicant:
Visa Type:

Visit Information

Eligibility Questions

Do you have any recent signs or symptoms that are undiagnosed?
Have you been hospitalized for a sickness in the last six months?
Have you been treated for anemia requiring iron supplements or blood transfusion in the past 12 months?
Do you know any reason why you would require Treatment during Your Policy Period?
Are you residing in a nursing home, rest home, convalescent home, rehabilitation centre or home for the aged or required assistance with any activities of daily living (bathing, eating, using a toilet, taking medication(s) or getting into or out of a chair or bed) where you reside in Canada?
In the 12 months prior to the effective date have you been prescribed home oxygen or prednisone for a lung condition or a heart condition or had Pulmonary Fibrosis or Cystic Fibrosis?
In the 12 months prior to the effective date have you use nitroglycerine in any form (spray, patch or pill) for a heart condition for the relief of angina or chest pain, or have a heart condition with an ejection fraction of LESS THAN 40%?
In the 12 months prior to the effective date have you had any aneurysm that is not surgically repaired?
Have you had a Bone Marrow transplant, stem cell transplant or an organ transplant except a cornea transplant?

Rate Classification Questions

Answers on the questions:
Each question below requires the applicant to answer either "Yes" or "No" depending on whether the applicant has had such a condition, including symptoms or investigation or consultation concerning a certain condition.
If the condition has been specifically ruled out and no further follow-up action has been or needs to be taken then the applicant can answer "No" to the condition.
If the applicant answers "Yes" to any condition, the applicant must state how many medications they are taking for that condition and for how long the condition has been stable.
Have you had CIRCULATORY, VASCULAR OR BLOOD DISORDERS in the last 3 years?:
High Blood Pressure (Hypertension) or Low Blood Pressure (Hypotension)
Vascular Disease (PVD) or Artery Disease (PAD)
Have you ever had symptoms or diagnosis for HEART OR CARDIOVASCULAR conditions?:
Cardiomyopathy, Congestive heart failure or water on the lungs or the use of Lasix or Furosemide
Any other heart or cardiovascular condition, heart attack, surgery, angioplasty, stent, by-pass, pacemaker, irregular rhythm, valve disorder, coronary artery disease or chest pain investigated by a doctor
Have you ever had symptoms or diagnosis for STROKE, CEREBROVASCULAR OR NEUROLOGICAL conditions?:
Stroke, Cerebrovascular accident (CVA), Mini Stroke, Transient ischemic attack (TIA)
Have you had RESPIRATORY OR LUNG conditions in the last 3 years?
Any chronic respiratory condition, lung disorder or lung surgery. (not including Asthma or minor ailments)
Have you had KIDNEY, GASTRO-INTESTINAL, DIGESTIVE OR LIVER conditions in the last 3 years?
Chronic Kidney Disease, Chronic Renal Failure, Pancreatitis, Hepatitis or Cirrhosis of the liver
Have you had DIABETES in the last 3 years?:
(If Insulin and oral medications are taken, both items (a and b) must be checked !)
Diabetes prescribed insulin
Diabetes prescribed medication (not insulin)
Diabetes without medication or impaired glucose tolerance
Have you ever had CANCER?:
Leukemia or Lymphoma or Multiple Myeloma
Have you had any other form of Cancer and not including basal cell or squamous cell skin cancer?
In the 6 months prior to the effective date have you had chemotherapy or radiation therapy for cancer or malignant tumour(s)?
Do you have any OTHER RISK FACTORS you would like to be covered?:
Have you had symptoms, been referred to a specialist or specialty clinic or required treatment or prescription medication or surgery for any other medical or physical disorder or condition not referred to above?  List them in the note section!
Syncope or dizzy spells or fainting that was reported to a doctor or hospital
In the 6 months prior to the effective date have you had two or more falls that were reported to a physician?
In the 6 months prior to the effective date have you received advice/treatment for a medical emergency in a hospital for any of the conditions listed above?

Submit your Questionnaire

Please confirm you are not a Robot: