short medical report by monkey6

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									short medical report

UNDERWRITTEN BY HOLLARD LIFE

A LT R I S K ( P T Y ) LT D i s a n a u t h o r i s e d f i n a n c i a l s e r v i c e s p r o v i d e r FSP 9869 P. O . B o x 2 9 4 4 - P i n e g o w r i e - 2 1 2 3 Te l + 2 7 1 1 3 2 9 7 0 0 0 l F a x + 2 7 1 1 3 2 6 0 1 2 3

Applicant’s Details
First Name Date of Birth
Y Y Y Y M M D D

Surname Reference No

Applicant’s Details (Must only be completed by the examining doctor/registered nurse)
I, employed by of (name of person making this declaration) or (name of medical practice or clinic) (practice number) declare that I have taken due and proper care to verify the true identity (Name of Applicant)

I have inspected the applicant’s: Identity Document Passport ID No. Passport No.

Other means of photographic identification in the form of I understand that no payment will be made for the examination unless this declaration is signed by me. Signed (Signature of Declarant)
Notes: Please record full and accurate answers and be sure to answer all questions. If the person to be examined completed the personal statement please check the answers given.

Date

1. Personal Statement
Has any proposal for life, health, sickness, accident or disability insurance on your life ever been declined, deferred, withdrawn or accepted on special terms or at special rates? If “Yes”, state particulars:

2. Medical History Do you have or have you ever had trouble with or disorders of any of the following? if “Yes”, state full details in the schedule following question 2.12 2.1 Disorder of the heart e.g. rheumatic fever, heart murmer, shortness of breath, palpitations, chest pain, Y N angina pectoris or coronary thrombosis? 2.2 High blood pressure, disease of the blood vessels or circulatory disorder, e.g. cramps in the calves Y N with walking or exercise, stroke, etc? Y N 2.3 Respiratory or lung trouble, e.g. asthma, bronchitis, persistent cough or tuberculosis? 2.4 Disorder of the digestive system, gall bladder, pancreas or liver, e.g. gastric or duodenal ulcer, recurrent Y N indigestion, hiatus hernia, rectal bleeding, piles or jaundice? 2.5 Disease or disorder of the kidneys, bladder or reproductive organs e.g. protein in urine, kidney stones, Y N prostatitis, cystitis or venereal disease? Y N 2.6 Nervous or mental disorder, e.g. epilepsy, blackouts, paralysis, anxiety or depression? Y N 2.7 Eye, ear, nose or throat disorder, e.g. defective vision, hearing loss or ear discharge? 2.8 Disorder or disease of the skin, muscles, bones, joints, limbs, or spine, e.g. rheumatism, arthritis, Y N gout, slipped disk or back trouble? Y N 2.9 Diabetes, sugar in urine, thyroid or other glandular or blood disorder?
Signature of Applicant Short Medical Report Page 1 of 4

2.10 2.11 2.12
Question Number

Cancer, growth or tumour of any kind? Any tropical disease, e.g. bilharzia or malaria? Any other illness, disorder, undergone any operation, disability or accident?
Nature, Duration and Severity of Complaint or Symptom Date Name & Address of Attending Doctor/Hospital

Y Y Y

N N N

When did you last have the symptoms?

3. Information required by female applicants
3.1 Have you ever had or do you currently have any disorder of the female organs (breasts, ovaries, uterus) or any abnormalities of pregnancy or confinement, e.g. caesarian section, miscarriage or abortion? If “Yes”, state full details and give the results of the latest Pap smear if applicable. 3.2 3.3 Are you pregnant now? If “Yes” how many months? When was your last child born?
Y N Y N

4. Tests and examinations
4.1 Have you ever been tested for or received any medical advice, counselling or treatment in connection with AIDS, any infection by one of the AIDS viruses, or any sexually transmitted disease (e.g. hepatitis B, gonorrhoea, syphilis)? 4.2 If not already stated, have you during the past 5 years: Had any X-rays, ECG’s, other examinations, and operations or been hospitalised? Taken any course of sedatives, tranquilizers or drugs for medical or other reasons? Please state past and present medication dosage and reason for use: Consulted any doctor or specialist including regular general checkup?
Exact Nature of Examination & Consultation Date Name & Address of Doctor, Specialist or Hospital

Y

N

Y Y

N N

Y
Result of examination and date of last symptoms

N

4.3

Name, address and telephone of your usual medical attendant and how long has he/she been your doctor?

5. Mass
5.1 Has your mass altered by more than 3kg’s over the past year?
Y N

If “Yes”, has it increased, decreased, by how much, for what reason and how long has your present mass been constant?

Signature of Applicant

Short Medical Report

Page 2 of 4

6. Habits
6.1 6.2 . 6.3 6.4 6.5 What kind and quantity of alcoholic liquor do you consume per day? Have you habitually taken more in the past or had an alcohol problem? If “Yes”, state full details including treatment Have you ever received medical advice to reduce or discontinue your liquor or tobacco consumption, or have you ever been charged with drunken driving? If “Yes”, please state full details.
Y N

Do you smoke? If “Yes”, state what you smoke and how much per day? Have you stopped or reduced smoking? If “Yes” please state date of change and your previous smoking habits per week?

Y

N

Y

N

Y

N

7. Family History Age Father Mother No. of Brothers No. of Sisters
7.2 If not already stated, have any close blood relatives had diabetes, heart disease, high blood pressure, mental illness, porphyria or any other hereditary disease? If “Yes”, state full details
Y N

If Living State of health

Age

If Deceased Cause of death

8. Risks
Are there any circumstances not disclosed above which might affect the risk of assurance on your life? If “Yes”, state full details
Y N

Declaration by the person whose life is to be assured
I declare and warrant that the given information is complete and true and also that this statement whether in my handwriting or not, together with any other relevant documents, shall be of the proposed contract of assurance.

Signed at

this

day of

20

Signature of Medical Examiner

Signature of person whose life is to be assured

Signature of Applicant

Short Medical Report

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Examination Please note: In order to avoid any embarrassment, the results of this examination are not to be disclosed to any unauthorised person.

9. Build and physical condition
9.1 9.2 Height (without shoes) Not needed in case of female applicant Chest (insp.) (exp.) (abdomen) Mass (In clothes)

10. Cadiovascular System
10.1 Blood pressure (to be taken in recumbent posture). Systolic Systolic 10.3 Pulse rate (resting) mm./hg. Diastolic mm./hg. Diastolic Is the pulse rate regular? mm./hg. mm./hg. 10.2 If BP is over 140/90 record a second reading at the end of the examination.

11. Genito - Urinary System
11.1 Is protein present? 11.2 Is glucose present? 11.3 Is blood present? 11.4 Is there any evidence of urobilinogen, pus, or mucus threads? 11.5 Is there any other abnormal finding?
Y Y Y Y Y N N N N N

Declaration
I DECLARE THAT ALL THE INFORMATION PROVIDED IS CORRECT AND TRUE. Signed at Name of examiner Qualifications Year of 1st qualifying Signature of examiner Notice to medical attendants: Altrisk will reimburse all medical accounts issued according to the insurance billing code. General Practitioner - Insurance billing code A1103 this day of 20

Full postal address of medical examiner

Tel: (Practice)

Signature of Applicant

Short Medical Report

Page 4 of 4


								
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