Name (please print): Date of birth: Year Month Day
Address: Street & Number
City Province Postal Code
Telephone Number (including area code): ( )
Patient’s Signature
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
(please specify):
BP readings over last 6 months (including dates)
Current height Current weight Weight loss/gain to date
Date symptoms first appeared
Date of first visit
Date patient’s condition first prevented them from working:
Date of latest visit:
Date of hospital inpatient admission:
Date of discharge:
Date of hospital outpatient admission:
Name of hospital:
Subjective symptoms (including severity/frequency/duration):
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Cardiac Form
1. Please PRINT.
2. Part 1 to be completed by patient.
3. Part 2 to be completed by physician.
4. Any charge for completion of this form is the patient’s responsibility.
Part 1: Patient Authorization
I authorize my healthcare or rehabilitation provider to disclose my personal information, including my medical and health information
and including consultation reports, to Canada Life Life for the purpose of investigating and assessing my claim(s), administering
coverage(s) that I may have with Canada Life Life and administering the group benefits plan. Medical and health information
excludes genetic test results.
I acknowledge that the personal information is needed by Canada Life Life for the purposes stated above. I acknowledge that my
consent enables Canada Life Life to process my claim(s) and refusing to consent may result in delay or denial of my claim(s).
This consent may be revoked by me at any time by sending a written instruction.
I confirm that a photocopy or electronic copy of this authorization shall be as valid as the original.
Part 2: Attending Physician’s Statement
1. Diagnosis (please provide copies of all relevant clinical notes, test results and consultation reports on file. Do not provide
genetic test results)
Frequency of visits:
Weekly Monthly Other
2. Findings
Chest pain of cardiac origin Syncope Fatigue Dyspnea due to vascular congestion or hypoxia
Psychophysiologic Other
Current status? Stable Improving Regressing
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Year Month Day
Medications (dose / frequency / date prescribed):
Other treatment (please describe):
Year Month Day Type:
Year Month Day Type:
Other treating physicians:
If No, please explain:
If yes, provide details:
Prognosis for recovery:
Year Month Day
Year Month Day
If your patient is unable to return to their regular occupation, please specify when and under what circumstances they could
return to work (eg. modified duties, gradual return to work)
M4307B(CF)-1/20 • 1-855-755-6729
Stress Thallium Test
Pulmonary Function Test
Blood Test
Surgery date (past):
Surgery date (future):
Standing hours
Walking blocks
Expected date patient will return to their own occupation:
If unknown, please indicate the next follow up date:
How does this affect the patient’s ability to perform
activities of daily living?
What specific restrictions or limitations prevent the patient
from performing the duties of his/her occupation?
3. Laboratory tests (completed/scheduled) - please include copies of relevant test results.
4. Treatment
Is patient compliant with prescribed treatment? Yes No
Has your patient been enrolled in a cardiac rehab program? Yes No
5. Restrictions and limitations
Functional capacity: (Canadian Cardio-Vascular Society (CCS))
Level 1 (no limitation) Level 2 (mild impairment) Level 3 (moderate impairment) Level 4 (severe impairment)
Weight Frequency Duration
Lifting/Carrying 1-10 lbs (0.5-4.5 kg)
11-20 lbs (5.0-9.1 kg)
21-50 lbs (9.5-22.7 kg)
Pushing/Pulling 1-10 lbs (0.5-4.5 kg)
11-20 lbs (5.0-9.1 kg)
21-50 lbs (9.5-22.7 kg)
Driver’s license revoked? Yes No
6. Return to work plans:
If yes to either of the above, please specify:
Attending Physician (please print) Certified Specialty
Address (Street, City, Province, Postal Code)
Telephone # (+ Area Code) Fax # (+ Area Code)
Email Address
Signature Date Signed (dd/mm/yyyy)
Is there any other information you wish to add that will give us a better understanding of your patient’s condition or treatment
M4307B(CF)-1/20 • 1-855-755-6729
Physician’s Stamp
Assessment and treatment are complicated by: (please select and explain in the space provided below)
Significant emotional or behavioral disorder such as depression, anxiety, etc.
Exaggeration, inconsistent findings, subjective complaints out of proportion to objective findings, bizarre or contradictory
Work-related issues (please describe if known)
Substance abuse
Other (please describe)
Is patient a suitable candidate for medical rehabilitation services (ie. cardiopulmonary program, speech therapy, etc.)?
Yes No
Is patient a suitable candidate for vocational rehabilitation? Yes No
Notice to Physician
The information in this statement will be kept in a life, health, or disability benefits file with the insurer or plan administrator and might be accessible
by the patient or third parties to whom access has been granted or those authorized by law. By providing the information I consent to such unedited
release of any information contained herein.