AAt the time of application, how many in total do you take OR have you been ordered to take by a physician for one or more of the following medical conditions: HEART, LUNG, DIABETES?
BWithin the 24 months prior to the date of application, have you had a: -HEART ATTACK -STROKE -MINI STROKE (TRANSIENT ISCHEMIC ATTACK (TIA)
CAt the time of application, how many of the following medical conditions are your receiving for? Place an X in each applicable box below.
DAt the time of the application, do you have any medical conditions that were not listed in the previous questions for which you are currently receiving ? (Treatment includes medication that you take OR have been ordered to take by a physician)
EIn the past 365 days, have you had an increase or decrease in your medication OR a change of health?
FDo you have any investigative tests or results pending the return of your trip or are you on a waiting list for ?
1In the 36 months prior to application, have you been diagnosed with, treated or been ordered by a physician to take medication for, three (3) or more of the following medical conditions? (Please check each condition below, which applies)
2In the 12 months prior to application, have you been diagnosed with, treated or been ordered by a physician to take medication for peripheral vascular disease (blocked leg arteries), congestive heart failure, chronic obstructive pulmonary disease (COPD, emphysema)?
3In the 12 months prior to application, have you used or been prescribed home oxygen?
4 A terminal condition or metastatic cancer?
5Did you have heart bypass surgery more than 10 years before application? (answer "no" to this question if you've had additional bypass surgery and/or placement of a stent less than 10 years prior to application)
6Have you had an organ transplant (excluding cornea or skin graft)?
7Do you have a kidney disease requiring kidney dialysis?
8Do you have an aneurysm larger than four (4) centimetres, measured in either length or diameter?
9In the 6 months prior to application, have you had a stroke or mini-stroke (tia or transient ischemic attack)?
10In the 5 years prior to application, have you been diagnosed with, treated or hospitalized for any of the following?
Heart attack, aneurysm, angioplasty, atrial fibrillation, artery bypass surgery, cardiac surgery, angina, congestive heart failure, irregular heartbeat, pacemaker, thrombosis, phlebitis, pulmonary oedema
Chronic asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), emphysema or pneumonia
Diabetes (requiring medication)
Stroke or mini-stroke (TIA or transient ischemic attack)
Carotid artery stenosis (blocked OR clogged arteries in the neck)
Cancer (excluding basal cell skin cancer)
Kidney disease that required dialysis, now no longer on dialysis
11In the 24 months prior to application, how many of the following medical conditions have you been diagnosed with, treated or ordered by a physician to take medication for?
12In the 12 months prior to application, have you been (1)diagnosed with, or undergone a change in medical treatment (including an alteration in medication dosage or usage) for high blood pressure
AND (2)had any of the following conditions?
Diabetes (not requiring medication)
13Have you ever been treated for a heart disease/condition (excluding congenital heart disease)?
14Was your last regular check-up with a physician more than 24 months ago?
15Have you had a fall that you reported to a physician in the last 6 months?
16In the 12 months prior to application, have you smoked tobacco products?