Medical Questionnaire
If you are over 60 at the time of travel, a medical questionnaire is mandatory.Have you been prescribed or taken medication, been diagnosed with or had an investigation, medical consultation or treatment for any of the following?
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1. Heart Condition or Cardiovascular Condition
Including but not limited to: Disorders of the Heart Rhythm or Conduction, Atrial Fibrillation, Arrhythmia or Bundle Branch Black, Pacemaker, Ablation or Implantable Cardioverter nDefibrillator
Heart Condition or Cardiovascular Condition:
Have you ever had heart bypass surgery?
Have you had an angioplasty or stent insertion?
Have you ever had Congestive Heart Failure (CHF)?
Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?
Are you prescribed a Nitro spray, patch, or pill?
Valvular heart disease or surgery
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2. Stroke, TIA, Mini-stroke or Cerebrovascular Condition
Stroke, TIA, Mini-stroke or Cerebrovascular Condition:
Have you had any change in stability in the last 12 months, including any new symptoms, investigations, diagnosis, or been prescribed or told to take any new medication, told to no longer take a type of medication, or had any dosage adjustments?
Are you prescribed a Nitro spray, patch, or pill?
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3. Lung Condition
Lung Condition:
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4. Neurological Condition
Neurological Condition:
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5. Peripheral Vascular, Artery, Vein Condition or Blood Clots
Peripheral Vascular, Artery, Vein Condition or Blood Clots
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6. Aneurysm or Arterial Enlargement
Aneurysm or Arterial Enlargement:
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7. Internal condition, including but not limited to: Disorders of the Stomach, Bowel, Gastrointestinal Tract, Kidney(including stones), Liver, Pancreas, Spleen, Prostate, Urinary Tract nor Gall Bladder(including stones)
Internal condition, including but not limited to: Disorders of the Stomach, Bowel, Gastrointestinal Tract, Kidney(including stones), Liver, Pancreas, Spleen, Prostate, Urinary Tract nor Gall Bladder(including stones):
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8. Blood Disorder
Blood Disorder:
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9. Diabetes
Diabetes:
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10. Cancer
Cancer:
Do you still have annual checkups with the oncologist?
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11. High Blood Pressure, Low Blood Pressure or Hypertension (including preventative medication)
High Blood Pressure, Low Blood Pressure or Hypertension (including preventative medication):
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12. High Cholesterol or Low Cholesterol (including preventative medication)
Answer "Yes" if you are taking medication to control your cholesterol or triglycerides
High Cholesterol or Low Cholesterol (including preventative medication):
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13. Other Medical Conditions
Other Medical Conditions:
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14. Tobacco Use
Tobacco Use:
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15. Annual Medical Checkup
Annual Medical Checkup:
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16. Hospitalization, ER Visit, or Surgery
Have you been hospitalized, visited the emergency room (ER), or had surgery in the last 12 months for any conditions asked about or not asked about?
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17. Assistance with Activities of Daily Living
Do you require any assistance from another person with Activities of Daily Living?
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18. Awaiting Surgery, Investigative Testing, or Diagnosis
Are you currently awaiting surgery, investigative testing or a diagnosis of any condition?
Thanks for filling that out!
A representative will contact you to finalize your quote