Akron General Hospital Discharge Form

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Akron General Hospital Discharge Form Powered By Docstoc
					                                               MEDICAL APPLICATION TO THE                                                       Part I
                                           First Catholic Slovak Ladies Association                                             Please Print

1.) Full Name of Proposed Insured:
                                                  Last                                  First                                   MI
2.) Address:
                    Street                                    City                                    State                     Zip
3.) Birthdate:                                                                                        Male          Single      Widowed
                    mm/dd/yyyy                    Age                                                 Female        Married     Divorced
1.) Has the proposed insured ever had any disease or disorder of: (If yes, circle condition and give details in No. 4)
a. Nervous system, epilepsy, or paralysis?                                                                             Yes      No
b. Heart or blood vessels; chest pains, high or low blood pressure, rheumatic fever?                                   Yes      No
c. Stomach, liver, intestines, gall bladder?                                                                           Yes      No
d. Kidney, urinary, bladder, prostate?                                                                                 Yes      No
e. Lungs; asthma, tuberculosis?                                                                                        Yes      No
2.) Has proposed insured ever had symptoms of or been affected with: (If yes, circle condition and give details in No. 4)
a. Cancer, tumor, diabetes, glands, or blood disorders?                                                                Yes      No
b. Any serious illness, disease or injury not already listed?                                                          Yes      No
c. Consultation, treatment or examination by physician or any practitioner for any other reason?                       Yes      No
3.) Height:            ___________ft _____________in Weight:    __________lbs Weight gained/lost in past year (REASON):             ____________
4. Give complete details of any "YES" answers to Questions 1 and 2. Give the full names and addresses of physicians
   seen or hospitals used within the last 5 years. Include dates, nature of disease or injury and treatment.
5.a) Family Record                                         Living                                                    Dead
                                          Age             Cronic Health Condition          Age at death                 Cause of Death
5b.) Have your parents, brothers, or sisters ever had heart disease, diabetes, cancer, or mental illness?           Yes             No
      If yes, please explain         ____________________________________________________________________________________
6.) In the past 5 years, have you used:                                    Details of Yes Answer: _________________________________________
a. Alcoholic beverages?            Yes            No                                              _________________________________________
b. Narcotic drugs?                 Yes            No                                              _________________________________________
7.) In the past 10 years, have you been treated for alcoholism or any drug habit?                 Yes        No
    If yes, please explain:        __________________________________________________________________________________________________
8.) In the past 10 years, have you been in a hospital, clinic, mental hospital, or institution for examination, observation, diagnosis,
    operation, or treatment?       Yes             No            If yes, please explain: _____________________________________________________
9a.) Are you now a cigarette smoker?                             Yes           No            If yes, please explain:    _____________________________
 b.) Have you been a smoker and quit?                            Yes           No                                       _____________________________
 c.) Did you quit within the past 6 months?                      Yes           No                                       _____________________________
    6 months to 1 year ago?                                      Yes           No                                       _____________________________
    more than 1 year ago?                                        Yes           No                                       _____________________________
d.) Did, or do, you smoke more than one pack daily?              Yes           No                                       _____________________________
10.) Has the proposed insured had life or health insurance rejected, rated up, postponed, modified, cancelled, or not renewed?
                     Yes          No               When?         _____________________   What Company?              _____________________________
I hereby agree that the above questions and answers shall form Part Two of my pending application for insurance in the FIRST CATHOLIC
I expressly waive on behalf of myself and of any person who shall have or claim any interest in any policy issued hereunder all
provisions of law for bidding any physician, hospital official or employee, or other person who has heretofore attended or examined
me, or who may hereafter attend or examine me, or who has been or may be consulted by me, from disclosing any knowledge or
information thereby aqcuired and from testifying with reference thereto, and I expressly authorize such persons to make such disclosures,
all to the extent permitted by law.
                                                                             Dated this ___________ Day of          ___________, 20_____

                    ____________________________________________                        _____________________________________________________
                             Paramed Examiner or Physician                                  Signature of Proposed Insured (Parent or Guardian if
                                                                                                  Proposed Insured is under the age of 16)

Form No. 2009-Med                                                          (Over)
                                           MEDICAL EXAMINER'S REPORT                                                                             Part II

1.) Proposed Insured's Full Name:__________________________________________________________________

2.) Proposed Insured's Temperature: __________ b. Pulse Rate: ______________           c. Intermittent or Regular? Describe:            ________________
3.) Proposed Insured's Height: ________________ Weight: ____________________
4.) GENERAL: Are there indications of disorder of:
a. Brain or Nervous System (Test Pupillary and Patellar Reflexes. Any tremors?)        Yes           No
b. Respiratory Organs (Throat, Nose, Sinuses)                                          Yes           No
c. Glands (Thyroid, Lymph, Endocrine, Etc.)                                            Yes           No
d. Blood Vessels (Arteriosclerosis, Varicosities, Etc.)                                Yes           No
e. Skin, Muscles, Bones, Joints (Deformity, Rheumatism, Etc.)                          Yes           No
f. Ears (Deafness, Discharge)                                                          Yes           No
g. Eyes (Vision, Etc.)                                                                 Yes           No
h. Musculo-Skeletal System                                                             Yes           No

5.) URINALYSIS:     a. Specific Gravity ________ b. Albumin: __________ c. Sugar? ______________ d. Is Specimin Authentic?              ________________
6.) HEART:
a. Are sounds and rhythm normal?                  _______________________________                                  If Murmur present, indicate
b. Murmurs present?                               _______________________________                                  1. Are Heard over by:
   Timing?                                        _______________________________                                  2. Point of greatest intensity by:
   Transmitted?                                   _______________________________                                  3. Direction of transmission by:
c. Degree of hypertrophy?                         _______________________________                                  4. Locate apex beat by:
d. Any dyspnea, cyanosis, etc?                    _______________________________
e. Diagnosis                                      _______________________________
7.) LUNGS: Are respiratory sounds normal in all areas with no evidence of rates, dullness, or other pathology?
                    Yes           No             Details      ___________________________________________________________________________
8.) ABDOMEN:        Is there evidence of tenderness or pathology developed by palpation of abdomen or pressure over liver, spleen, region of
appendix, gall bladder, or kidneys?                 ________________________ a hernia?
                                                                        Is there                     Yes           No
9.) Is there anything unfavorable about proposed insured's appearance, manner, mentality, gait, dress or occupation, or do you know or
   suspect anything concering habits, morals, or other circumstances not otherwise covered which, in your opinion, might affect the
   risk adversely?                ____________________________________________________________________________________________________

10.) FEMALES:       Has the proposed insured ever had any disorder of menstruation, pregnancy, or of the female organs or breasts?
                    Yes         No                If Yes, explain        ________________________________________________________________
b. To the best of her knowledge and believ, is the proposed insured now pregnant?                  Yes          No

11.) What, in your judgement, is the character of the risk: first class, good, fair, or poor? (if not first class or good, please state reason for
     lower rating.)               ____________________________________________________________________________________________________

I certify that I have carefully examined           ____________________________________________      whose signature is affixed to the foregoing
declaration, and the examination was made private at (circle one) my office, proposed insured's residence or place of business
on this __________________          day of ______________    20________
Examined at___________________________________________________________________________________________________
                                             City                                    State                        Zip

Paramed Examiner or Physician________________________________________________________ Date_____________________

                                                     IMPORTANT NOTICE TO MEDICAL EXAMINER
                                      This report is the property of the First Catholic Slovak Ladies Association.
                       It must not be given to the branch officer or agent/recommender, withdrawn, or destroyed by anyone.

Form No. 2009-Med

Description: Akron General Hospital Discharge Form document sample