1. Have you lived in Canada for less than 12 months ? ---yesno 2. In the past two years, have you had an application for critical illness insurance declined or postponed by any company, including Industrial Alliance ? ---yesno 3. Do you currently suffer from, or have you ever suffered from or had symptoms of any of the following illnesses or ailments, or have you ever consulted a doctor or been treated for: a) Congenital cardiac defects, angina, angioplasty, coronary artery bypass, heart attack, congestive heart failure, stroke, transient ischemic attack (TIA) or any other cerebrovascular disease or disease of the heart or the blood vessels, or an abnormal electrocardiogram (ECG) ? ---yesno b) Type 1 (insulin-dependent) diabetes or type 2 diabetes ? ---yesno c) Cancer or other malignant disease, tumour, colon polyp or any other growth ? ---yesno d) Any breast problems (mass, cyst, unusual discharge, physical change, abnormal mammogram or biopsy) or prostate problems (nodule or abnormal PSA) ? ---yesno 4. a) Currently, are you under medical investigation or have you been advised to undergo a diagnostic test or surgery that has not yet been carried out ? ---yesno b) Have you noticed any symptoms or health problems for which you have not yet consulted a doctor, such as: abnormality, lump or mass on the breasts, shortness of breath, chest pain, dizziness, loss of balance, numbness, rectal bleeding, prostate or other problems ? ---yesno 5. Have you tested positive for or received test results that indicate the presence of any one of the following diseases: a) HIV (AIDS virus), AIDS or other AIDS-related illness ? ---yesno b) Hepatitis B or C, chronic type D hepatitis, or carrier of hepatitis B ? ---yesno 6. In the last five years, have you undergone detoxication treatment (in-patient or out-patient treatment program) for alcohol or drug use ? ---yesno 7. In the last five years, have you used any hard drugs such as opium, heroin, morphine, codeine, Demerol, barbiturates, amphetamines, cocaine, hallucinogens or anabolic steroids, other than as prescribed by a doctor, or methadone, whether prescribed by a doctor or not ? ---yesno 8. Family History Do two (2) or more members of your immediate family (father, mother, brothers, sisters) suffer from, or have they suffered from cancer, heart disease, stroke or transient ischemic attack (TIA) before the age of 60 ? ---yesno 9. Does your current weight exceed the weight indicated for your height in the table below ?---yesno Name Phone Mobile No. Email
