Pre Medical Examination Format ( Mer Form ) 4i26u

Star Health and Allied Insurance Co. Ltd. MEDICAL EXAMINATION REPORT (To be filled in by the Medical Examiner) Name of the person to be insured: ____________________________________________________________________ Date of birth: _________________

Age: _____________

Sex:

Marital Status: ________________ Occupation: _____________________________________ Identification Marks:(1) ________________________________________(2)_________________________________ 1. Measurement & Vitals Height(Cms)

BP *

Weight (Kgs)

Systolic

Diastolic

BMI

Waist Circumference (cms)

Pulse Rate /Rhythm

Respiratory rate

I Reading: II Reading: III Reading: *If the Systolic reading is 140 or more or Diastolic reading is 90 or more, second and third reading should be taken with 10 minutes interval of rest. 2. Personal Physician / Last Consultation: Name and address of your personal physician (if none, state the name of the doctor last consulted)

Date of last consultation

Reason

3. Past History Details of medical illness in the past

Period

Details of surgery/procedure undergone in the past

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Star Health and Allied Insurance Co. Ltd.

4.(a) If the person to be insured is presently suffering from any of the following diseases, please give details: DISEASE

DURATION & DETAILS OF DRUGS TAKEN

DM/HTN Orthopedics and related diseases

CVA/Neurological Diseases

Heart Disease/Respiratory Illness

Mental Illness

Renal Disease

Cancer

Other (specify)

(b) Within the past 4 years had he/she undergone any diagnostic test like blood test, ECG, CT Scan, MRI etc., If yes, please give details ________________________________________________________________________________

( c ) Details of illness for which OP treatment, IP treatment taken or any check up done during last one year.

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Star Health and Allied Insurance Co. Ltd. (d) General Examination Built Nutrition Anaemia Cyanosis Clubbing Pedal edema Lymphadenopathy Others

5. Examination of systems SYSTEMS ENT & Opthalmology Any evidence of cataract or surgery done for cataract (or) Any other visible eye conditions. Are there any missing teeth? If so, give details, Mouth Ulcers, Leucoplakia, etc., Are there DNST/T & A/Ear Discharge & Hearing Loss

YES

NO

DETAILS

Respiratory System. Are there any abnormality or diseases of the respiratory system like TB, Asthma, COPD etc.? Cardiovascular System Is examination of CVS normal ? Abdomen Is there any organomegaly ? Any Ascites Surgical Scar – if any Is there any evidence of Hernia, hydrocele, undescended testis, chronic ulcer etc., Nervous Systems Is there any evidence of neurological disorder such as epilepsy, wasting, involuntary movements, paralysis etc., Muscle Skeletal System Examination of limbs, spine & ts

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Star Health and Allied Insurance Co. Ltd. SYSTEMS For female only Is there any disease of the breasts? ( Lump ) Do you suspect any disease of ovaries uterus, cervix

YES

NO

DETAILS

6( a) Family History: Parents If alive Parent Age

Present Health Status

Age at death

If NOT alive Cause of Death

Father

Mother (b) Family History: Diseases of parents If any other family member is suffering from any of the following diseases, please give details Relationship with the person to be insured

DM

HTN

CVA

Heart Disese

Renal Cancer diseases

Mental Illness

Others (Please specify)

Medical Examiner’s Opinion : Are there any Pre-Existing diseases? If yes , give details

Any other remarks.

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Star Health and Allied Insurance Co. Ltd.

Is the person to be insured, related or known to Medical Examiner?

Signature of the person to be insured.

Yes/No

Name of the Medical Examiner. Signature & seal.

Place:_________________

Date:____________

Address:____________________________

To be filled in by the Company’s doctor/ doctor Details of pre-existing diseases of the person to be insured to be incorporated in the policy:(1) (2) (3)

Name of doctor: __________________

Signature and Seal: _________________

Place: _______________

Address:____________________________

Date: ____________

________________________________________________________________________________________________

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