Ottawa Life Insurance - Basic Medical Questionnaire

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Basic Medical Questionnaire

50 and older Canadian residents can get up to $35,000 in life insurance coverage

Rates start as low as $10/month per $3,000 in coverage

**based on standard health quotes, and are fully underwritten

This is a basic medical questionnaire. If you were sent this link or directed to this page, kindly complete the medical questionnaire and submit it in order to save time with your dedicated licensed advisor who will be able to make further recommendations based on your health. All questions are mandatory.

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Name:

Date of Birth:

Gender:

Smoking Status: In the past twelve (12) months, have you used any substance or product containing tobacco, nicotine, or marijuana mixed with nicotine or used e-cigarettes?

Your Height

Your Weight

Are you currently:

Admitted to a hospital?

Residing or are you on a waiting list to reside in a long-term care facility, nursing home, skilled nursing facility or any other facility requiring care of a skilled staff?

No None of the above

Are you aware of any signs, symptoms, or any abnormal diagnostic test for which:

You have not yet consulted a physician?

You are currently being investigated?

You have a pending consultation with a medical specialist?

You have consulted with medical specialist without having received a diagnosis?

You are currently awaiting for a surgery (other than day surgery/outpatient surgery)?

None of the above

Have you ever:

Been diagnosed with, hospitalized for, or undergone treatment (including medication) for cystic fibrosis, HIV, AIDS, or AIDS-related complex?

Been diagnosed with or undergone treatment (including medication) for muscular dystrophy, Huntington's disease, amyotrophic lateral sclerosis (Lou Gehrig’s disease), Alzheimer's disease, or dementia?

Been advised by a physician that you have a terminal illness for which you are currently receiving Palliative or Hospice care or have discussed this type of care with a health professional?

None of the above

Have you Ever: Received a bone marrow transplant or an organ transplant (other than a corneal transplant) or were you advised that one was required?

Have you Ever: Been diagnosed with or hospitalized for congestive heart failure or cardiomyopathy?

Have you ever been diagnosed with or hospitalized for: Chronic kidney disease or polycystic kidney disease (PKD) or undergone dialysis?

Have you ever been diagnosed with or hospitalized for: Angina or a heart attack or undergone coronary angioplasty (with or without a stent insertion) or coronary artery bypass surgery?

Have you ever been diagnosed with or hospitalized for: A cerebrovascular accident (stroke)?

Have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for leukemia or cancer (other than basal cell carcinoma)?

In the past five (5) years, have you: Been advised by a health professional to discontinue your consumption of alcohol or drugs, or have you received advice or treatment (including medication) for alcohol or drug abuse?

In the past five (5) years, have you: Used narcotics, barbiturates or steroids (other than prescribed by a physician)?

In the past five (5) years, have you: Used any unprescribed drugs (other than marijuana products or over the counter medications), including but not limited to cocaine, LSD, amphetamines, hallucinogens?

In the past five (5) years, have you: Used any prescribed or non-prescribed marijuana products more than 6 times per week?

In the past five (5) years, have you: Been accused or charged with alcohol-related or a drug-related driving offence or refused a breathalyser?

In the past five (5) years, have you: Been incarcerated, convicted of a crime or violation of any law, or are you currently accused of a crime or violation of any law for which a verdict has not yet been rendered?

Have you ever been diagnosed with diabetes (other than gestational diabetes)?

Have you ever required the administration of oxygen for a chronic respiratory disorder (other than sleep apnea)?

In the past three (3) years, have you been: Hospitalized for any respiratory disorder?

In the past three (3) years, have you been: Treated with oral Prednisone or other oral corticosteroid for any respiratory disorder?

Have you ever been diagnosed with or hospitalized for: Hepatitis B or C?

Have you ever been diagnosed with or hospitalized for: Cirrhosis of the liver?

Have you ever been diagnosed with or hospitalized for: Chronic pancreatitis?

Have you ever been diagnosed with or hospitalized for: Two (2) or more episodes of acute pancreatitis?

In the past twelve (12) months, have you loss more than 10% of your current body weight (other than due to pregnancy, intentional dieting or exercise)?

Do you have a biological family member (father, mother, brother, sister), who was diagnosed with Huntington’s disease or polycystic kidney disease, and for which you have not been investigated for these diseases?

In the past ten (10) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: (a) Convulsions, epilepsy, transient ischemic attack (TIA or mini-stroke), a spinal cord or brain tumor?

In the past ten (10) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: Bipolar disorder, schizophrenia, or psychosis?

In the past ten (10) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: Multiple sclerosis or Parkinson’s disease?

In the past ten (10) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: Rheumatoid arthritis or paralysis?

In the past ten (10) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: Heart murmur or arrhythmia?

In the past ten (10) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: Crohn' disease or ulcerative colitis?

In the past ten (10) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: Glomerulonephritis, scleroderma or SLE (Systemic Lupus Erythematosus)?

Is your driver's license currently suspended or revoked as a result of any driving infractions?

In the next twelve (12) months, do you expect or plan to travel outside North America, the Caribbean (excluding Haiti), or Western Europe for more than four (4) weeks??

In the next twelve (12) months, do you expect or plan to engage in any hazardous sports or activities, or aerial flights other than as a passenger, commercial pilot, or crew member of a commercial flight?

In the past six (6) months, have you required a new medication for high blood pressure or an increase in the dosage of any medication for high blood pressure?

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Ottawa, ON, Canada

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Basic Medical Questionnaire

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