Visitor to Canada Plan Medical Declaration

Answer the following questions to determine eligibility.

First name:*
Last Name:*
01. Within the past 12 months, have you been newly diagnosed with, been prescribed any new medication or change in dosage, frequency or type of medication, had any new or change in treatment (including investigation or testing), been referred to a specialist physician for investigation or testing, or been hospitalized or seen in the emergency department of a hospital, for any of the following: a) a heart condition; b) a lung condition; c) shortness of breath; d) chest pain; e) stroke, mini-stroke or TIA (Transient Ischemic Attack)?*
02. Have you: a) been diagnosed with a heart valve disorder which has not been treated by heart valve surgery; b) had heart bypass or valve surgery or angioplasty more than 10 years ago? (use the date of your most recent procedure) *
03. Have you ever been diagnosed with congestive heart failure?*
04. Within the past 12 months have you: a) been treated for and/or been diagnosed with internal bleeding; and/or b) been admitted to hospital for a gastrointestinal disease or disorder; and/or c) received treatment (including investigation or testing) for any cancer (except basal cell and squamous cell skin cancer)?*
05. Within the past 12 months, have you been prescribed or taken any of the following: a) Lasix or furosemide for any reason; b) prednisone for any lung condition; c) medications for both diabetes and a heart condition (you can answer no to this question if you are medicated for one of these conditions but not both. Also, medication prescribed solely for the control of blood pressure does not count as a medication for a heart condition); d) any form of nitroglycerin for the relief of angina pain (including on an “as needed” basis)?*
06. In the past 2 years, have you: a) been prescribed or taken Lasix or furosemide for any condition; and/or b) had congestive heart failure; and/or c) required treatment with oxygen or prednisone (or other oral steroid medication, not including puffers) for a lung condition?*
07. Have you ever received an organ transplant? *

*By submitting this form you hereby consent to Insufin Inc's right to use the information provided to contact you.