SLEEP APNEA QUESTIONNAIRE

When answering the questions on this form, DO NOT provide information about any genetic test
you have taken or plan to take. A genetic test is a type of medical test that analyzes DNA, RNA or
chromosomes. DO provide information about other types of medical tests.

Name of Proposed Insured:

Raymond San Agustin Application/Policy No: N658344

1. a. When were you diagnosed with sleep apnea?

March 2018
b. Please describe the severity of your sleep apnea: n Mild n Moderate n Severe
■

2. From the following list, please indicate all symptoms that led to the initial diagnosis of sleep apnea as well as any symptoms you
currently experience:

Symptoms at time of initial diagnosis Current symptoms

Snoring n ■ Yes n No n Yes n
■ No
Long pauses in breathing/gasping during sleep n
■ Yes n No n Yes n
■ No
Daytime sleepiness n
■ Yes n No n Yes n
■ No
Fatigue or lack of energy n
■ Yes n No n Yes n
■ No
Headaches n Yes n
■ No n Yes n
■ No
Forgetfulness or difficulty concentrating n Yes n
■ No n Yes n
■ No
Moodiness, irritability or depression n Yes n
■ No n Yes n
■ No
Insomnia or restless sleep n
■ Yes n No n Yes n
■ No
Others (specify): n Yes n
■ No n Yes n
■ No

3. a. What tests have been completed for this condition? Please specify the type of test(s), date(s) and results:
Take home sleep study March 2018 - moderate sleep apnea

b. Have any tests or investigations been recommended but not yet completed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n
■ No
If yes, please specify the nature of the test(s) or investigation(s) and date(s) scheduled:

n
4. a. Has any treatment(s) been prescribed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ■ Yes n No
If yes, please list all treatment(s) and dates prescribed (e.g. CPAP, oral device, etc):
CPAP

b. How often do you use this treatment during sleep? n

■ Daily n Occasionally n Never
c. Effect of treatment on your symptoms: n
■ Improved n Eliminated n No change n Unknown
d. Has surgery been suggested, scheduled or performed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n
■ No
If yes, please specify the details, including the type of surgery, date scheduled or performed or if you are on a waiting list:

VPS 99934 110111 (12/2017)

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 SLEEP APNEA QUESTIONNAIRE
When answering the questions on this form, DO NOT provide information about any genetic test
you have taken or plan to take. A genetic test is a type of medical test that analyzes DNA, RNA or
chromosomes. DO provide information about other types of medical tests.

Raymond San Agustin N658344

Name of Proposed Insured: Application/Policy No:

5. Have you ever lost any time from work due to sleep apnea? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n
■ No
If yes, please provide the details, including dates and duration of time off work:

6. Do you currently have, or have you ever had in the past, any restrictions, limitations or
modifications of your daily activities or work duties due to sleep apnea? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n Yes n
■ No
If yes, please describe any restrictions, limitations or modifications of your daily activities or work duties, dates and duration:

7. Please provide the full names and addresses of all physicians, health care professionals, hospitals and health care facilities consulted
for sleep apnea and the date of all consultations:
Dr. Rashid Malek at Transcanada Medical center
Funktional Sleep Solutions
Essence clinic - Respiratory Therapists

I declare that the answers I have given on this questionnaire are true and complete and shall form part of my application.

Signature of Proposed Insured: Date:

20.Aug.2019
(Day/Month/Year)

® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.

VPS 99934 110111 (12/2017)
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