Do you belong to any of the following occupations ?
- Air Traffic Controllers
- Blasters and anyone handling explosives or acids
- Cable Men
- Carnival & Circus Employees/Performers/Rodeo Performer
- Divers and diving attendants
- Window cleaners - over 2 stories
- Employee of Cocktail Lounges, nightclubs or Taverns (where
- liquor is primary business)
- Firefighters: airfields, jumpers
- Fisherman (gulfs, oceans, seas, not coming home daily)
- Hazardous materials Truck Driver
- Professional Divers
- Stunt Workers
- Mining - underground workers
- Marine Industry: barges/tugs ocean, wrecking and salvage
- Off Shore Workers (Oil and Natural Gas)
- Structural Iron or Steel Workers - towers, bridges buildings
- over 2 stories, cable car
- Logging Industry: Raftsmen, Rivermen, River Drivers, Topmen,
High Climbers, Fallers, Cutters, Buckers, Boomsmen, Pondmen,
Boomstick Borers, Riggers, Chokermen
Within the past 10 years, have you suffered from, received
treatment, medication, medical advice, care, service or diagnosis
for, had known indication of, had a positive test for or consulted
a physician about any of the following :
- cancer, tumor, enlarged glands or leukemia ?
- any disease or disorder of the immune system; such as but
not limited to Acquired Immune Deficiency Syndrome (AIDS)
AIDS Related Complex (ARC), or Human Immunodeficiency Virus
- abnormal blood pressure, stroke, any disease or disorder of
the heart or circulation (such as chest pain, angina or heart
attack) or lungs (such as asthma, pneumonia or emphysema)
- dizzy or fainting spells, epilepsy, paralysis, neurological
disorder, depression, psychiatric disorder or suicide attempt
- any disease or disorder of the stomach (other than flu or
minor ailments), intestines or colon, liver, kidney, bladder
or reproductive organs ?
- diabetes, thyroid disorder, hepatitis, hepatitis carrier state
or any blood or glandular disorder ?
- been advised to seek treatment or medical advice, been advised
to reduce alcohol consumption or attended an organization
because of alcohol use ?
Within the past 2 years, have you had any
- symptoms of or treatment for any medical condition that resulted
in overnight hospitalization (other than normal pregnancy,
gall bladder removal, appendectomy, any fracture of bone that
doesn't require operation or an operation for bunions) ?
- abnormal electrocardiogram, chest x-ray (other than broken
ribs), laboratory test or studies (other than for kidney stones
or gall stones) ?
Are you aware of any symptoms or complaints regarding
your health for which you have not yet consulted a physician
or received treatment or have you been advised to have further
examination, diagnostic testing, treatment or surgery that
has not yet been scheduled or completed ?
Within the past 12 months, have you consulted a doctor
or health care practitioner, received any treatment or counseling,
had any diagnostic tests or been prescribed or taken medication
for any reason other than the following:
- regular annual checkup with no further investigations or
follow ups <
- regular cold and/or flu (with antibiotic treatment or no treatment
- Ministry of Transport physical with normal results
employment medical with normal results
- normal pregnancy
- kidney stones, gall stones, vasectomy, tubal ligation, appendectomy
- musculoskeletal disorders such as dislocations, fractures,
- minor injuries, back or muscle strain
Within the past 5 years, have you had your driver's
licence suspended, been convicted of impaired driving or had
5 or more moving violations or used any illegal drugs (other
than marijuana or hashish), such as cocaine, heroine, LSD,
etc., or been treated for drug abuse ?
Within the past 3 years, have you:
- lived outside of Canada on a permanent basis or do you intend
to travel outside of North America other than for vacation
or business reasons for more than 2 months ?
- participated in aviation (other than as a fare paying passenger)
scuba diving, mountain or rock climbing, skydiving or any
other hazardous activities, or do you have any intention to
do so in the future ?
- received a disability benefit from any source or missed 15
or more consecutive days from work or school due to illness
- had any application for Life, Disability or Critical Illness
insurance declined, postponed, cancelled, rescinded, rated,
modified or issued other than applied for in any way ?