Eligibility Assessment Part A
1. Do you require assistance with 2 or more of the activities of daily living, such as, but not limited to, getting up, walking, bathing, showering, washing, toileting, taking medication, dressing or feeding?
2. Are you a resident of a long-term care facility, nursing home, nursing facility or assisted living residence?
3. Are you bedridden or wheelchair bound, regardless of your place of residence?
4. Have you ever been advised to receive, or are you on a waiting list for, or are you the recipient of, an organ or bone marrow transplant (excluding corneal transplant)?
5. Within the last 60 days, have you been admitted to a hospital for more than 48 consecutive hours (excluding pregnancy)?
a. Have you ever been advised to have surgery or a procedure, or an investigation or diagnostic test of any type (excluding annual tests with normal results), or to consult with a medical professional or facility, that has not yet started or been completed or the result of which is not yet known, or
b. have you ever not followed treatment or not taken medication advised or prescribed by a medical professional, or
c. within the last 60 days have you had or been advised of an abnormal test result that changed existing treatment or resulted in new treatment for an ongoing condition?
7. Referring to the Height and Weight table for this question, is your weight greater than that indicated for your height?
|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
8. Have you ever tested positive for Human Immunodeficiency Virus (HIV) or had been told you have, or been treated for, Acquired Immunodeficiency Syndrome (AIDS), Aids Related Complex (ARC), or a disease or disorder of the immune system excluding lupus, rheumatoid arthritis or type 1 diabetes?
9. Have you ever had or been told you have, or been investigated (with positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for:
a. metastatic cancer, a recurrence of cancer, or a second diagnosis of cancer (excluding basal cell carcinoma) or
b. a chronic lung or respiratory condition (excluding sleep apnea), such as, but not limited to, Chronic Obstructive Pulmonary Disease (COPD), emphysema, or pulmonary fibrosis, which requires or required the periodic use of oxygen or the use of a steroid (excluding steroid treatment for asthma) or
c. dementia, Alzheimer’s, memory loss, Muscular Dystrophy, myotonic dystrophy, Parkinson’s disease, Huntington’s Chorea or Amyotrophic Lateral Sclerosis (ALS) or
d. congestive heart failure, systolic or diastolic heart failure or cardiomyopathy?
10. Prior to age 40, have you had or been told you have, or been investigated (with positive or unknown result) or treated, or taken medication, or been advised to take or prescribed medication for cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, atherosclerosis, stroke (CVA), transient ischemic attack (TIA), chronic kidney disease, aneurysm anywhere in your body or had heart bypass surgery, angioplasty or stent insertion?
11. Within the last 12 months, have you:
a. used (except as prescribed by a medical professional) a narcotic or barbiturate or
b. used (whether prescribed by a medical professional or not) heroin, a psychoactive drug, cocaine, crack, methadone, fentanyl or another similar agent or
c. been in a hospital or facility for drug or alcohol treatment?
12. Within the last 24 months, have you been convicted, incarcerated, on probation or parole, or is a charge pending or are you awaiting sentencing, for a criminal offence?
13. Have you ever been diagnosed with a life threatening, critical, or terminal condition for which a medical professional has estimated that you have a reduced life expectancy?