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Visitors to Canada Insurance
Medical Questionnaire

If you have questions, or need help to complete the form, please call at
416-493-0101, 1-877-443-010
1-877-443-0101

 I confirm that I understand and meet eligibility requirements above:

Applicants 60 + years of age must answer the following questions to determine insurance rate.

Yes

No

If you have any doubt about your medical condition (s) as it relates to the following questions, you should consult your physician for advice before completing this medical health questionnaire.

You are eligible for coverage if:

At the time of application, you are:

•

a) A foreign worker, international student studying in Canada or a visitor to Canada with valid legal status in Canada; or,

•

b) An immigrant awaiting provincial or territorial government health care coverage; or,

•

c) A Canadian returning to Canada from an extended leave who is eligible for but not yet covered by a provincial or territorial government health care plan.

•

You know of no reason for which you may seek medical attention.

•

You are not traveling against a physician's advice.

•

You have not been diagnosed with a terminal condition.

•

You are not receiving palliative care or palliative care has not been recommended.

Do you have pancreatic cancer, liver cancer or any type of cancer that has metastasized or that required a bone marrow transplant?

Do you have Chronic Obstructive Pulmonary Disease (COPD), including emphysema, requiring home oxygen?

Have you had or are you waiting for an organ transplant?

Have you been diagnosed with Congestive heart failure also known as pulmonary edema?

Do you have kidney disease requiring dialysis?

None

Stroke and/or Transient Ischemic Attack (TIA) also known as mini-stroke

Myocardial infarction also known as heart attack

Arterial by-pass, angioplasty and / or placement of a stent for a cardiovascular condition

QUESTION 1: Have you had any of the following in the last 12 months?

No

Yes

Yes

Yes

No

No

Yes

Yes

No

No

None

Diabetes requiring insulin

Liver disease, excluding liver cancer

Asthma

Pneumonia

Chronic Obstructive Pulmonary Disease (COPD), including emphysema, not requiring home oxygen

Yes

No

QUESTION 2: Have you had any of these conditions in the last 12 months?

Atrial fibrillation

Coronary Artery Disease (CAD)

Arteriosclerosis and / or atherosclerosis also known as hardening of the arteries

QUESTION 3: In the last 12 months, have you smoked any tobacco products, or vaped any nicotine products (including e-cigarettes)?

Country of origin:

Destination in Canada:

Age:

Name:

Number of Days in Canada:

Please enter your E-mail:

Please confirm you are not a Robot:

Choose a condition if, in the specified timeframe, you had the condition, whether or not you received any medical care for it.


This includes conditions controlled or managed by medication, a medical device, diet or exercise.

Coronary Artery Disease can be caused by arteriosclerosis and/or atherosclerosis.

If you’ve been diagnosed with CAD and arteriosclerosis and/or atherosclerosis, choose all these conditions.

Atrial fibrillation is a type of arrhythmia.  Choose this condition if you’ve been diagnosed specifically with atrial fibrillation and not any other type of arrhythmia or

dysrhythmia.