Yes No



  • is travelling against the advice of a physician;
  • has been diagnosed with or been given a life expectancy of 6 months or less;
  • has been prescribed and/or used home oxygen within the past 24 months
  • has been prescribed or recommended the use of dialysis in the last 12 months;
  • is under 15 days old, or are age 89 years or older;
  • resides in a nursing home, home for the aged, other long-term care facility or rehabilitation center; or
  • requires assistance with activities of daily living
  • is awaiting or received an organ transplant
  • has ever had any cancer with metastasis (which includes positive lymph nodes), or undergone chemotherapy (of any form, except cream) in the last 6 months
  • has been diagnosed with or treated for Congestive Heart Failure

Yes No