1 Lady Travel Travel Boarding Pass Passport Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Doctor Map

Where do you live?

Where are you going?

How long will you be away?

Departure Date
Return Date

Who is traveling?

Name
Email
Phone
Date of birth

Medical Questionnaire

If you are over 60 at the time of travel, a medical questionnaire is mandatory.Have you been prescribed or taken medication, been diagnosed with or had an investigation, medical consultation or treatment for any of the following?


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1. Heart Condition or Cardiovascular Condition

Including but not limited to: Disorders of the Heart Rhythm or Conduction, Atrial Fibrillation, Arrhythmia or Bundle Branch Black, Pacemaker, Ablation or Implantable Cardioverter nDefibrillator

Heart Condition or Cardiovascular Condition:
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2. Stroke, TIA, Mini-stroke or Cerebrovascular Condition

Stroke, TIA, Mini-stroke or Cerebrovascular Condition:
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3. Lung Condition

Lung Condition:
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4. Neurological Condition

Neurological Condition:
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5. Peripheral Vascular, Artery, Vein Condition or Blood Clots

Peripheral Vascular, Artery, Vein Condition or Blood Clots
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6. Aneurysm or Arterial Enlargement

Aneurysm or Arterial Enlargement:
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7. Internal condition, including but not limited to: Disorders of the Stomach, Bowel, Gastrointestinal Tract, Kidney(including stones), Liver, Pancreas, Spleen, Prostate, Urinary Tract nor Gall Bladder(including stones)

Internal condition, including but not limited to: Disorders of the Stomach, Bowel, Gastrointestinal Tract, Kidney(including stones), Liver, Pancreas, Spleen, Prostate, Urinary Tract nor Gall Bladder(including stones):
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8. Blood Disorder

Blood Disorder:
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9. Diabetes

Diabetes:
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10. Cancer

Cancer:
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11. High Blood Pressure, Low Blood Pressure or Hypertension (including preventative medication)

High Blood Pressure, Low Blood Pressure or Hypertension (including preventative medication):
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12. High Cholesterol or Low Cholesterol (including preventative medication)

Answer "Yes" if you are taking medication to control your cholesterol or triglycerides

High Cholesterol or Low Cholesterol (including preventative medication):
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13. Other Medical Conditions

Other Medical Conditions:
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14. Tobacco Use

Tobacco Use:
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15. Annual Medical Checkup

Annual Medical Checkup:
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16. Hospitalization, ER Visit, or Surgery

Have you been hospitalized, visited the emergency room (ER), or had surgery in the last 12 months for any conditions asked about or not asked about?
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17. Assistance with Activities of Daily Living

Do you require any assistance from another person with Activities of Daily Living?
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18. Awaiting Surgery, Investigative Testing, or Diagnosis

Are you currently awaiting surgery, investigative testing or a diagnosis of any condition?

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