Standard_Examination_Form by peirongw

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									HEALTH PREDICTIONS LIFE INSURANCE MEDICAL SERVICES
STANDARD EXAMINATION FORM
Medical Report to Insurance Company for Paramedical, General Practitioner and Specialist Medical Examinations

The applicant should complete the personal statement in his/her own words prior to the examination and the medical Examiner will discuss the answers and add any details considered appropriate. The document should be signed in the Examiner’s presence.

Duty of Disclosure  Under the Insurance Contracts Act 1984 the applicant has a duty to complete this application honestly and to disclose everything he/she knows, or could reasonably be expected to know, which might affect the insurance company’s decision to provide insurance, and to decide what premiums and conditions will apply. Failure to comply with this duty, allows the insurance company to cancel the policy or reduce the amount of cover. This Duty of Disclosure continues up to the date that the insurance company accepts the application and issues a policy, or in the case of an addition to an existing policy. The duty also exists until the insurance company issues a revised schedule.

 

Insurance Company:

Advisor:

PERSONAL STATEMENT
Details of client
Mr Surname: Mrs Miss Ms Other

Habits
Do you drink alcohol? No Yes Go to the next question What form eg. Beer, spirits, wine?

Given Names:

Average weekly quantity?

Address:

If no, have you ever drunk alcohol? No Yes Go to the next question What form eg. Beer, spirits, wine?

Date of Birth: Occupation and industry:

/

/
Average weekly quantity? Date ceased

/
Previous occupation

/

Have you smoked tobacco or any other substance or used any nicotine-containing product in the last 12 months? No Yes Go to the next question What type eg. cigarettes, gum, patch?

Occupational duties:

Are you in receipt of any pension? Give details Daily quantity? Have you had or are you contemplating war service? Date ceased

/

/

Details of treating practitioner
Surname:

If not, have you ever smoked tobacco or any other substance or used any nicotine-containing product? No Go to the next question What type eg. cigarettes, gum, patch?

Given Name:

Yes

Daily quantity? Address:

Date ceased

/

/

P/code

Have you used, by mouth, inhalation or injection, any drug not prescribed by a doctor? No Go to the next question What type and when?

Date last seen: Condition for which last seen

/

/
Yes

Medical History
(Tick appropriate box) Have you EVER had any of the following: 1 Heart disorder, vascular disorder (including varicose veins), high blood pressure, high cholesterol, chest pain or heart rhythm abnormality? Lung disorder, asthma, bronchitis or coughed blood? Diabetes, stomach or liver disorder, hepatitis, gall bladder disorder, bowel disorder, haemorrhoids, blood in the stools, diarrhoea, swallowing disorder or vomiting blood? Kidney, bladder, prostate disorder or blood in the urine? Swollen glands, anaemia, blood disorder or haemophilia? Yes No

Medical History
(Tick appropriate box) 16 Any medical investigation or test (eg: genetic test, mammogram, ECG, ultrasound)? Have you HAD any operation, illness, injury or symptoms not yet described in this document? Do you NOW have any other disability, illness, injury or symptoms not yet described in this document? Have you taken any prescribed medication on a regular or ongoing basis (other than for cold and flu)? Do you contemplate seeking any advice, test, investigation, treatment or operation? Are you currently pregnant (females)? Yes No

17

2 3

18

19

4

20

5

21 6 Neurological disorder (including spinal cord stroke, epilepsy, fits, fainting, migraine, persistent headache or chronic fatigue? Joint, neck or spine disorder including back strain, sciatica, whiplash, spondylisis, disc disorder or lumbago, arthritis, gout, rheumatism, repetitive strain injury or any disorder of the muscles? Skin disorder, cyst, mole or other lesion? Disorder of the eyes, ears, nose or throat? Emotional, psychiatric or mental disorder or treatment or counseling for one or more of these conditions? Infections, night-sweats or unintended change in weight (last 12 months)? Disorder of the reproductive system, breasts, abnormal pap smear (females) or sexually transmitted disease? Any allergies or anaphylactic shock? Alcohol or drug dependence, or any professional advice to reduce alcohol consumption, or used (by mouth inhalation or injection) any drug not prescribed by a doctor other than medicines purchased from a chemist? Any form of cancer or leukemia? C D

HIV
A Have you been infected by the virus which causes AIDS (HIV) or are you carrying antibodies to that virus? In connection with AIDS or related conditions, have you sought or are seeking medical investigation or are you expecting to receive treatment? Have you requested a test for HIV? Are you suffering any unintentional weight loss, persistent night sweats, fever, diarrhea or swollen glands? Between 1980-1985 inclusive, did you receive a blood transfusion, treatment with blood products or organ transplant? Since 1980 have you: worked as or engaged in sexual activity with a prostitute or anal sexual activity or been injected with a drug not prescribed by a registered medical practitioner? Do you believe any of your sexual partners since 1980 would answer YES to any question between B5-B10?

7

B

8

9

10

11

E

12

F

13 14

G

15

Write details of all ‘YES’ answers to questions on the previous page.

Item Code (see above)

Illness, injury, condition or test

Test results

When did it start?

When did it cease?

Type of treatment

How long off work?

Name & address of Institution and attending person

Family History
Give details of your family medical history Living relatives Relative Current age Mother Father Brothers Specify current state of heath (if not good, state reason) Age at death Specify cause of death (please state fully and exactly) Deceased relatives

Sisters

Has any near blood relative suffered from diabetes, high blood pressure, high cholesterol, heart disease, stroke, mental disorder or breakdown, kidney disease, haemophilia, Huntington’s chorea, cystic fibrosis, muscular dystrophy, familial polyposis of the colon, cancer or any hereditary diseases? No Yes Give details

Declaration
I declare that my answers to the questions in this Personal Statement are true and correct. I agree that Health Predictions or the Insurance Company is authorized to obtain any information from any medical practitioner in relation to the insured. I understand that this Personal Statement forms part of my proposal for insurance Signature of life to be insured Signature of Medical Examiner Date: Date: / / / /

CONFIDENTIAL MEDICAL REPORT
The examiner is requested not to express to the examinee any opinion concerning the examinee’s insurability.

Measurements
Give the following measurements: Height (without shoes)

Introduction
Client Name:

Weight (clothed) Are you acquainted with the examinee: Professionally? No Yes Go to the next question State circumstances Chest and abdomen Chest expiration
(males - at nipples females – below the breasts)

kg

cm cm cm

Chest inspiration Abdomen (at umbilicus) Personally? No Yes Go to the next question State circumstances

If the chest expansion is less than 5cm, comment as to the apparent cause.

Respiratory System

Is there anything unfavourable in appearance, development or behaviour? No Yes Go to the next question Give details

1

Is there any abnormality of the respiratory system to palpation, percussion or auscultation? No Yes Go to the next question Give details

Is there any indication of past or present abuse of alcohol or the misuse of drugs? 2 No Yes Go to the next question Give details Is there any sign of past of present respiratory disease? No Yes Go to the next question Give details

Circulatory System
1 What is the rate and character of the pulse? Pulse rate Character Per minute

Circulatory System
6 What is blood pressure (ausculatory method)?

The diastolic level is to be taken at the cessation of all sound. If the first systolic reading is above 135 or below 100, or the diastolic above 85 or below 60, two further readings at 5-10min. intervals are required. The recumbent position should be used where possible.

Systolic 2 What is the position of the apex beat of the heart? In the interspace cm Systolic mmHg Systolic mmHg No Yes Go to the next question Give details 7 mmHg

Diastolic mmHg Diastolic mmHg Diastolic mmHg

From the mid-sternal line.

3

Is there any evidence of cardiac enlargement?

Is there any abnormality of the peripheral arterial or venous circulation. No Yes Go to the next question Give details

4

Is there any abnormality in the heart sounds or rhythm? No Yes Go to the next question Give details

8

Do you consider the heart and vascular system to be abnormal? No Yes Go to the next question Give details

5

Is there any murmur present? No Yes Go to the next question Describe fully

9

Is the examinee now on treatment for hypertension? No Yes Go to the next question If known, please advise a) Pre-treatment BP level & dates

b) Duration of treatment

c) Nature of treatment

Digestive & Lymphatic Systems
1 Is there any abnormality of tongue, mouth or throat? No Yes Go to the next question Give details

Genito-urinary & Reproductive Systems
1 Examination of the urine.

The urine should be passed at the time of the examination. State the circumstances.

If albumin is found, an early morning specimen should be examined and findings recorded before completing the report. a) Albumin b) Glucose 2 Is there any abnormality or evidence of disease of any abdominal organ, including liver or spleen? No Yes Go to the next question Give details 2 Is there any evidence of abnormality of the genitourinary system? No Yes Go to the next question Give details c) Ketones c) Blood d) Bile

3

Is there any abnormality of the lymph nodes in the neck, axillae or inguinal regions? No Yes Go to the next question 3 Give details Is the examinee pregnant?

Females Only

No Yes 4 Is a hernia present? No Yes Go to the next question 4 Describe fully No Yes

Go to the next question Expected confinement date

/

/

Are the breasts abnormal to palpation? Go to the next question Give details

Nervous System
Is there any defect of vision or abnormality of the eyes? No Yes Go to the next question Give details

Musculo-skeletal System and Skin
Is there any abnormality in the form or function of the joints, muscles or connective tissue?

No Yes

Go to the next question Give details

Is there any defect in hearing or speech? No Yes No In case of present or past ear discharge or deafness, state result of auriscopic examination Yes Go to the next question Give details Is there any abnormality in the form or function of the back or neck including the cervical and lumbar spine?

Is there any evidence of mental abnormality? No Yes Go to the next question Is there any evidence of any disorder of the skin? Give details No Yes Go to the next question Give details

4

Is there any evidence of any disorder of the central or peripheral nervous system? No Yes Go to the next question Please give details

Summary
Do you consider any medical attendant’s reports or any special tests are required?

Summary
: / /

Dated at

am/pm

on

No Yes

Go to the next question Give details

Place

Signature of Nurse or Medical Examiner

2

Do you consider the person examined to be likely to require any surgical operation? No Yes Go to the next question Give details

Name and address of Nurse or Medical Examiner (BLOCK LETTERS)

Qualifications of Nurse or Medical Examiner

3

Comment fully on any unfavourable features (either physical or mental) which could either reduce life expectancy or cause disablement: a) in the personal medical history

Attachments checklist (if applicable): Client information, consent & ID form Any documents left by the client Specific symptom supplementary form/s Electrocardiogram Exercise stress test Pathology results

b) disclosed by your medical examination Include a GST Tax Invoice with your report and return immediately after completion to: Health Predictions Life Insurance Services PO Box 138 EAST MELBOURNE VIC 3002


								
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