Gender
1. Have you discussed or taken steps with a healthcare professional concerning a request for medical assistance in dying (MAID)?
2. In your lifetime, have you had, or been told you had, and/or been treated for any of the following conditions:
a. Acquired immunodeficiency syndrome (AIDS) or tested positive for the human immunodeficiency virus (HIV)?
b. Heart failure or cardiomyopathy?
c. Cystic fibrosis, Alzheimer's disease, dementia, Huntington's chorea, Parkinson's disease, amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), muscular dystrophy, myotonic dystrophy or any form of ataxia?
d. Chronic respiratory disease (excluding sleep apnea) which requires the daily administration of oxygen or the use of a ventilator?
e. Have you received an organ transplant, or a bone marrow transplant, or were you advised to do so due to your condition?
f. Before age 40, have you had, or been told you had, and/or been treated for any of the following conditions: cardiac chest pain or angina, heart attack, heart valve disease, heart disease, arteriosclerosis, cerebrovascular disease (stroke) or transient ischemic attack (TIA)?
3. Within the last five (5) years:
a. Have you had an amputation as a result of a disease?
b. Have you been treated and/or been in a hospital for drug or alcohol use, joined a support group, been advised to reduce your consumption, or to receive treatment for it?
c. Have you been convicted, sentenced, incarcerated, on probation or parole or charged for a criminal offense (including offenses associated with driving under the influence-DUI)?
d. Did you receive a record suspension or a pardon or an unconditional discharge?
4. Within the last three (3) years:
a. Have you had, or been told you had, or been treated for leukemia, lymphoma, malignant tumor or any form of cancer (other than basal cell carcinoma)?
b. Relating to a cancer diagnosis, has a healthcare professional prescribed you an antineoplastic such as Anastrozole (i.e. Arimidex), Letrozole (i.e. Femara) Exemestase (i.e. Aromasin) or hormone therapy (i.e. tamoxifen)?
c. Have you used any hard drugs except as prescribed by a physician or have you used drugs such as methadone, Narcan, Naloxone or Suboxone (including all generic versions) prescribed or not by a physician?
5. Are you:
a. Presently hospitalized or in a nursing facility including a centre or a home for individuals with reduced autonomy?
b. Presently bedridden or wheelchair bound?
c. Presently awaiting surgery or been advised to undergo surgery that has not yet been completed?
d. Presently awaiting a test (excluding routine annual tests), procedure or test result, or have you been advised to have a test or procedure that has not yet been completed?
e. Aware of any abnormal test(s) or exam(s) for which further evaluation was required which has not yet been completed?
f. Waiting for an appointment with a specialist for a diagnostic investigation?
g. Experiencing any signs and/or symptoms for which you have not yet consulted a medical professional?
6. Is your weight greater than the weight corresponding to your height in the following table?
| Height (ft/in) | Weight (lbs) | Height (m) | Weight (kg) |
|---|---|---|---|
| 4'5" - 4'7" | 188 | 1.33 - 1.41 | 86 |
| 4'8" - 4'10" | 210 | 1.42 - 1.49 | 95 |
| 4'11" - 5'1" | 233 | 1.50 - 1.56 | 106 |
| 5'2" - 5'4" | 255 | 1.57 - 1.64 | 116 |
| 5'5" - 5'7" | 280 | 1.65 - 1.72 | 127 |
| 5'8" - 5'10" | 310 | 1.73 - 1.79 | 141 |
| 5'11" - 6'1" | 340 | 1.80 - 1.87 | 154 |
| 6'2" - 6'4" | 363 | 1.88 - 1.95 | 165 |
| 6'5" - 6'7" | 400 | 1.96 - 2.01 | 181 |
| 6'8" - 6'10" | 430 | 2.02 - 2.08 | 195 |
1. Within the last two (2) years:
a. Have you had a life insurance application declined or postponed?
2. Within the last five (5) years:
a. Have you had, been told you had, or been treated (including dialysis) for chronic kidney disease (chronic kidney insufficiency of any degree, chronic kidney failure, Polycystic kidney disease (PKD) or any other types of chronic kidney disease (CKD))?
b. Have you had, been told you had, or been treated for a chronic liver disease (including cirrhosis, fibrosis, hepatitis C, or any other types of chronic hepatitis)?
3. Within the last three (3) years:
a. With regards to cardiac chest pain or angina, heart attack, heart valve disease, arteriosclerosis or heart disease:
Have you been diagnosed and/or been treated with anticoagulants and/or antiplatelets?
Have you undergone surgery (including bypass, angioplasty, pacemaker, or insertion of a stent or prothesis)?
b. With regards to cerebrovascular disease (stroke), transient ischemic attack (TIA) or vascular disease of the arms and/or legs (excluding varicose veins and superficial phlebitis):
Have you been diagnosed and/or been treated with anticoagulants and/or antiplatelets?
Have you undergone surgery?
4. Within the last twelve (12) months:
a. Have you undergone surgery for an aneurysm?
b. With regards to depression or any mental health disorder:
Have you been hospitalized?
Has your medication been changed by a healthcare professional (addition or replacement of a medication, increase or decrease of dosage)?
Have there been times where you did not follow your treatment plan as established by a healthcare professional (including medication)?
c. If you have diabetes:
Has your medication been changed by a healthcare professional (addition or replacement of a medication, increase or decrease of dosage)?
Have there been times where you did not follow your treatment plan as established by a healthcare professional (including medication)?
d. If you have high cholesterol and/or blood pressure:
Has your medication been changed by a healthcare professional (addition or replacement of a medication, increase or decrease of dosage)?
Have there been times where you did not follow your treatment plan as established by a healthcare professional (including medication)?
5. Within the next two (2) years:
a. Do you foresee travelling to high-risk regions or regions of conflict or war?
b. Do you intend to reside outside Canada or the USA for at least six (6) consecutive months?
1. Is your weight greater than the weight corresponding to your height in the following table?
| Height (ft/in) | Weight (lbs) | Height (m) | Weight (kg) |
|---|---|---|---|
| 4'5" - 4'7" | 170 | 1.33 - 1.41 | 77 |
| 4'8" - 4'10" | 190 | 1.42 - 1.49 | 86 |
| 4'11" - 5'1" | 210 | 1.50 - 1.56 | 95 |
| 5'2" - 5'4" | 235 | 1.57 - 1.64 | 107 |
| 5'5" - 5'7" | 255 | 1.65 - 1.72 | 116 |
| 5'8" - 5'10" | 280 | 1.73 - 1.79 | 127 |
| 5'11" - 6'1" | 305 | 1.80 - 1.87 | 138 |
| 6'2" - 6'4" | 335 | 1.88 - 1.95 | 152 |
| 6'5" - 6'7" | 355 | 1.96 - 2.01 | 161 |
| 6'8" - 6'10" | 380 | 2.02 - 2.08 | 172 |
2. Within the last five (5) years:
a. Have you had or been told you had or been treated for leukemia, lymphoma, malignant tumor or any form of cancer (other than basal cell carcinoma)?
b. Relating to a cancer diagnosis, has a healthcare professional prescribed you an antineoplastic such as Anastrozole (i.e. Arimidex), Letrozole (i.e. Femara) Exemestase (i.e. Aromasin) or hormone therapy (i.e. tamoxifen)?
3. Within the last twelve (12) months, has your weight decreased by 10% or more (excluding after a diet or childbirth)?
4. Family history. Has a member of your immediate family (father, mother, brother or sister) been diagnosed before age 60 with any of the following conditions:
a. Huntington's disease or Polycystic kidney disease (PKD)?
Your Information
Province of Residency
Proceeds of Benefit Amount(s)
Who would you like to receive the Benefit Amount(s)?
Choose all that apply.
Affordability Guidelines
The Guaranteed Access Program is designed to offer you the highest benefit at the most affordable cost.
2. When was the last time you used tobacco in any form (including cigarettes, cigars, cigarillos, marijuana/cannabis mixed with tobacco, electronic cigarettes, gum, patches, chewing tobacco or snuff, betel nuts, shisha, hookah / water pipe, etc.)?
2. Were you born in Canada?
3. Do you have a family doctor or a regular health care facility?
Who is your family doctor or a regular health care facility?
Your doctor may be contacted by telephone and/or in writing to validate the information.