Sun Life Financial / Financière Sun Life

Member and dependent details

Please complete the following medical/lifestyle questions for yourself and your dependents. If you answer yes to any question, please provide further details including dates, treatment and medications as applicable.

Information marked with an * is required.

2.3 Medical information - Questions 14 to 25 of 30

14.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having cancer, malignancy, leukemia, or enlarged lymph nodes?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

15.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having illnesses of the heart or circulatory system?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

16.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having a liver disorder or hepatitis?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

17.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having a kidney disorder?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

18.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having a lung or respiratory disorder (including asthma)?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

19.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having a neurological disorder?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

20.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having psychiatric or psychological problems, including anxiety, depression or panic disorders?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

21.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having chronic fatigue syndrome or fibromyalgia?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

22.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having a musculoskeletal, joint or bone disorder, including arthritis?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

23.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having back or neck problems?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

24.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having high blood pressure?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

25.	* Within the last three years have you received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having a gastrointestinal disorder, including esophageal, colon or bowel disorders?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

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