Bluecross – Health Questionnaire Please enable JavaScript in your browser to complete this form. - Step 1 of 2Name Insureds Name Date of Birth Height WeightIs the Insured on Any Prescription Medication?NoYesName/Dosage/Length of Treatment for All Prescription MedicationsAre the prescriptions refillable?Has the Insured Consumed any Nicotine, Tobacco, Alcohol or Cannabis Products in the Last 12 Months?NoYes Details of Daily/Weekly or Monthly Consumption Habits Has the Insured Ever Received or Been Advised to Undergo Treatment or Counselling for Drug/Alcohol Abuse?NoYesDoes the Insured Use Unregulated Substances (Street Drugs)?YesNo Is the Insured Currently Pregnant?NoYesNextHas the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Cardiovascular ConditionNo YesStroke/CVA, Transient Ischemic Attack, Heart Attac, Angina, High Blood Pressure, Chest Pains, Palpitations, Heart Murmur, High Cholesterol...Details of Condition/Treatment Has the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Respiratory System IssuesNoYesAsthma, Chronic Bronchitis, Cystic Fibrosis, Emphysema, COPD, Sleep Apnea...Details of Condition/Treatment Has the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Digestive System IssuesNoYes Ulcerative Colitis, Chron's Disease, Hepatitis, Chronic Pancreatitis, IBS.... Details of Condition/Treatment Has the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Issues with the Kidneys, Bladder or Reproductive OrgansNoYesDetails of Condition/Treatment Has the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Neurological ConditionNoYesParkinson's, Multiple Sclerosis, Chronic Headaches, Dizziness, Vertigo, Epilepsy, Paralysis... Details of Condition/Treatment Has the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Mental Illness NoYes Details of Condition/Treatment Has the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Muscular-Skeletal Condition/IssuesNoYesArthritis, Muscles or Bone Issues, Ligament Issues, Neck or Back Pain...Details of Condition/Treatment Has the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Immune System IssuesNoYesDetails of Condition/Treatment Has the Insured Ever Consulted, Been Treated for, Shown Symptoms of, or Been Diagnosed With - Any Medical Condition Not MentionedNoYesDetails of Condition/Treatment Does the Insured Have Any Referrals Pending, Testing or Investigations Pending by Medical Professionals Relating to Any Health Conditions?NoYesDetails of Condition/Treatment Does the Insured Use Any Medical/Prostetic Devices?NoYesCPAP Machine, Artificial Limbs, Cane, Wheelchair, Braces (excluding teeth), Orthopedic Shoes, Pacemaker...Details of Condition/Treatment In the Last 2 Years, Has the Insured Received Treatment from a Registered Health Specialist NoYesChiropractor, Psychologist, Physiotherapist, Naturopath...Details of Condition/Treatment Date of Last Physician VisitReason for Last Physician Visit and Details of Condition/Treatment (if any)MessageSubmit Comments Comments are closed.
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