medical examination form full

Full Name of Proposed Insured : Date of Birth : __________________

Proof of Identity ( Please check ) : Identity Card No. ____________________________ Passport No : _____________________

Driving License No. __________________________ Others : _________________________

1. (a) When did you last consult a physician ? ____________________________________________________________________________

(b) Please state reason for consultation : ______________________________________________________________________________

( c )What treatment, if any, was prescribed : ____________________________________________________________________________

(d) Please state name and address of physician : ________________________________________________________________________

2. Have you ever been treated for or ever had any known indications of : 7. Family History :( CIRCLE APPLICABLE ITEMS ) Yes No Tuberculosis, diabetes(a) Disease or disorder of eyes, ears, nose or throat ? cancer, high blood pressure

heart or kidney disease Yes No(b) Dizziness, fainting, convulsions, headache, speech defect, mental illness of suicide?

paralysis or stroke, mental or nervous disease or disorder ?

© Shortness of breath, persistent hourseness or cough, bloodspitting, bronchitis, pleurisy, asthma, emphysema, tuberculosis if living Death

or chronic respiratory or lung disease?

(d) Chest pain, palpitation, highblood pressure, rheumatic fever,heart murmur, heart attack or other disease of the heart or Fatherblood vessels?

(e) Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, colitis,diverticulitis, hermorrhoids, recurrent indigesion or other diseaseof the stomach, intetines, liver or gallbladder? Mother

(f) Sugar, albumin, blood or pus in urine, venereal disease, stoneor other disease of kidney, bladder, prostate or reproductive organs?

Brothers(g) Diabetes, thyroid or other endocrine disease?

(h) Neuritis, sciatica, rheumatism, arthritis, gout or diseaseor disorder of the muscles or bones, including the spine,back or joints? Sisters

(I) Deformity, lameness or amputation ?

(j) Disease of skin, lymph glands, cyst, tumor or cancer?Children

(k) Allergies, anemia or other disease of the blood?

3. Are you now under observation or taking treatment or medicationfor any disease of disorder? Number Living : _______________________

4. Have you had any change in wright in the past year? Number Dead : _______________________

5. Have you within the past 5 years :

(a) Had any mental or physical disease or disorder not listed above 8. Females Only :

(b) Had a check-up, consultation, illness, injury or surgery? (a) Have you had anydisorder or

( c )Bveen a patient in a hospital, clinic, sanatorium or other medical manstruation,facility? pregnancy or of the

female organs Yes No(d) Had electrocardiogram, X-ray, other diagnostic test? or breasts?

(e) been advised to have any diagnostic test, hospitalization orsurgery which was not completed? (b) Are you now Pregnant Yes No

(if yes, how many months)

6. Please state current consumptions of Any Additional Information :

Tobacco : _________ day / week Alcohol : ________________ day / week____________________________________

If you do not smoke cigarettes now but did so previously, when did stop ? ____________________________________________________________________ ____________________________________

I declare that I am the person named as the proposed insured and that the above statements and answers are true and complete to thebest of my knowledge and belief. I confirm that they are correctly recorded and are a continuation of and form a part of the applicationon my life to Al Sagr National Insurance Company.

Signed at : _______________________________________ Signature of Proposed Insured : ___________________________________

on this ______ day of ______________________ 20______ Signature of Medical Examiner : ___________________________________

MEDICAL EXAMINATION REPORT

THE FOLLOWING QUESTIONS ARE TO ASKED AND RECORDED BY THE EXAMINER

Age Age atState of Health/

cause of death?

DECLARATION

Please send this report promptly to Al Sagr National Insurance Company


1. When an Examination is begun the report thereof becomes the property of the company and must not be suppressed of destroyedregardless of your recommendations and regardless of whethere the proposed insured or any other person offers to pay themedical fee in order to avoid a declination.

2. An Examiner is not permitted to examine his own patients or relative or applicants of an agent who is a relative.3. Any erasures or alternations in your report must be initialed by you.4. Both the statement of the proposed insured on the reverse side and the medical examiner's report must be recorded in your handwriting.

How long have you know the proposed insured ? Years ________ Months _________. Are you related ? _________________________

9. (a) 10. Blood Pressure

Please record 3 readings taken at intervals of atleast5 minutes in either of the following circumstances.(a) First reading is over 140 systolic or 90 diastolic

or (b) There is a history of hypertension.(b) Did you weigh? Yes No Did you measure? Yes No

( c ) Is appearance unhealthy or older than stated age ? Yes No Systolic ( 4th Plase )

11. Pulse (Change of

Please exercise sufficiently to increase rate by atleast 25 beats per minute sound )

after exercise.Diastolic

Rate ( 5th Plase )(Disappearance

Irregularities of sound )

per minute* if applicant discloses a history of treated

12. Heart hypertension, please complete hypertension questionnaire

Enlargement Yes No Dyspnea Yes NoIf the answer to any question is "Yes", identity

Murmur (s) Yes No Edema Yes No question number and list complete details.

(describe below - if more than one, describe separately)

Indicate:

Location

Constant

Inconstant

Transmitted

Localized

Systolic

Diastolic Please comment and give your impression?

Soft (Gr 1-2)

Mod. (Gr 3-4)

Loud (Gr. 5-6)

After Excecise Increased

Absent

Unchanged

Decreased

* If there is history of coronary artery disease, please complete CAD Questionnaire




MEDICAL EXAMINATION REPORT ( continued )


at Umbilicus

cms

INSTRUCTIONS TO THE MEDICAL EXAMINER

MEDICAL EXAMINER'S CONFIDENTIAL REPORT

Kilos cms cms cms

Abdomen(in shoes) (clothed) (Full Inspiration) (Forced Expiration)

Height Weight Chest Chest

1 32

At Rest 3 Minutes LaterAfter Exercise


DECLARATION

1 2

Apex by

Murmur area by

point of greatest

intensity by

Transmission by


1. When an Examination is begun the report thereof becomes the property of the company and must not be suppressed of destroyedregardless of your recommendations and regardless of whethere the proposed insured or any other person offers to pay themedical fee in order to avoid a declination.

2. An Examiner is not permitted to examine his own patients or relative or applicants of an agent who is a relative.3. Any erasures or alternations in your report must be initialed by you.4. Both the statement of the proposed insured on the reverse side and the medical examiner's report must be recorded in your handwriting.

13. Is there on examination any abnormality of the following: If the answer to any question is "Yes", identity(circle applicable items and give details) Yes No question number and list complete details.

(a) Eyes, ears, nose, mouth, pharynx ?( if vision or hearing markedly impaired, incidate degree and correction ).

(b) Skin : Lymph nodes : vericose veins or peripheral arteries?

( c )Nervous system (indicate reflexes, gait, paralysis )?

(d) Respiratory System ?

(e) Abdominal Organs ( indicate scars )?

(f) Genitourinary system ?

(g) Endocrine system (include thyroid and breasts)?

(h) Musculoskeletal system (include spine, joints,amputations, deformities)?

14. Are there any hernias?

15. Are you aware of additional medical history?( a confidential report may be sent to the medical director )

16. Urinalysis 17. Do you know or suspect anything adverse aboutthe proposed insured's health, character,mentality, habits or morals not otherwise covered above ?

Yes NoIn addition to your urinalysis, please arrange to microscopic analysis ata qualified laboratory in the following circumstances: ( a confidential report may be sent to the (a) If requested by the company medical director )(b) Any urinary abnormality is found or suspected, In the case of _______________________________________

albuminuria please arrange for applicant to produce a second earlymorning specimen. _______________________________________

( c )There is a history of hypertension, kidney, prostate, bladder orgeniro-urinary disease within the last two years. _______________________________________

If the answer to any question is "Yes", identity question number and list complete details :




MEDICAL EXAMINATION REPORT ( continued )


INSTRUCTIONS TO THE MEDICAL EXAMINER

MEDICAL EXAMINER'S CONFIDENTIAL REPORT ( continued)

Specific Gravity Albumin Sugar


DECLARATION

medical examination form full

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