Eligibility Assessment Part A
1. Are you currently incapable of independently carrying out two or more of the basic activities of daily living such as getting up, walking, washing, toileting, dressing or feeding?
2. Are you currently a resident of a long-term care facility, nursing home, nursing facility, or assisted living residence?
3. Are you in need of an organ transplant, on a waiting list for an organ transplant or the recipient of an organ transplant (excluding corneal transplants)?
4. Within the past 30 days, have you been admitted to a hospital for more than 48 hours (excluding pregnancy)?
5. Within the past 60 days, have you been advised by a physician:
a. Of any abnormal diagnostic tests?
b. To have surgery or a diagnostic test or special test of any type?
c. To consult with a physician, medical institution or specialist that has not yet been completed?
6. Have you ever been diagnosed with a life threatening, critical or terminal condition for which a physician has estimated that you have 24 months or less to live?
7. Have you ever had, been told you have, or been treated for Acquired Immunodeficiency Syndrome (AIDS) or have you ever tested positive for Immunodeficiency virus (HIV)?
8. Within the past ten years, have you had, been told you have, been treated for, or been advised to have an investigation, that has not yet been completed, for:
a. Metastatic cancer or more than one occurrence of cancer (excluding basal cell carcinoma)?
b. Cystic Fibrosis or a chronic respiratory condition (excluding sleep apnea) which required the continuing administration of oxygen?
c. Dementia, Alzheimer's, Muscular Dystrophy, Huntington's Chorea or Amyotrophic Lateral Sclerosis (ALS)?
d. Congestive heart failure or cardiomyopathy?
9. Have you ever had, been treated for, or been diagnosed prior to age 40, with: chronic kidney disease, stroke (CVA), transient ischemic attack (TIA), aneurysm, coronary artery disease, heart bypass surgery, angioplasty, stent insertion, angina or heart attack?
10. Within the past 12 months, have you used narcotics or barbiturates (except as prescribed by a physician), heroin, psychoactive drugs, cocaine, crack or other similar agents, or been a resident of a drug or alcohol treatment facility?
11. Within the past 12 months, have you been convicted of, awaiting sentencing for, incarcerated for, or on probation for a criminal offence; or do you currently have any criminal charges pending?
12. Is your weight greater than that indicated for your height in the following table?
|4'8" - 4'10"
||142 - 147 cm
|4'11" - 5'1"
||148 - 155 cm
|5'2" - 5'4"
||156 - 163 cm
|5'5" - 5'7"
||164 - 170 cm
|5'8" - 5'10"
||171 - 178 cm
|5'11" - 6'1"
||179 - 185 cm
|6'2" - 6'4"
||186 - 193 cm
|6'5" - 6'7"
||194 - 201 cm