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Are you presently hospitalized, confined to a nursing facility,
bedridden or confined to a wheelchair, or have you been advised
that this is required due to your present condition?
Within the past two (2) years:
- Have you had an amputation caused by disease?
- Have you been hospitalized for:
- heart failure
- Alzheimer's disease/dementia
- malignant tumour
- cancer
- leukemia
- chronic kidney disease
- liver disease
- diabetic coma or insulin shock
- Were you informed that you had any of the above conditions?
- Have you received medical or surgical care, or were medications
prescribed for any of the above conditions?
Within the past two (2) years have you been hospitalized
for:
- Chronic respiratory condition that required the administration
of oxygen?
- Heart attack
- Coronary artery disease
- Angina
- Stroke or other cerebrovascular disorder
Were you informed that you had any of the above conditions?
Within the past five (5) years, have you:
- recieved an organ transplant or a bone-marrow transplant
or have you been advised that one was required due to your
condition?
- tested positive for HIV or undergone treatments (including
medication) for AIDS, AIDS-related complex (ARC) or any other
immune system disorder?
- been diagnosed or treated (including medication) for an illness
such as amyotrophic lateral sclerosis (Lou Gehrig), progressive
bulbar paralysis, cor pulmonate, or any other incurable terminal
illness?
Were you informed that you had any of the above conditions?
Within the past two (2) years have you had any application
for insurance declined or postponed?
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