@ BAJA 5|Allianz@ Bajaj Allianz General Insurance Company Limited Lyset ‘PART; PERSONAL HISTORY Please ask the following quesion tothe person tobe assured belre caring out your examination, ay Ue NETO) eee a Full Name I L owsee CTT TTTTT me RANE ee ee ae ee ee ee an ei “Cie ee eens “Pin qe gee aaNe = 2 ee oes areas va oe : If yes please sve parol indding deta of any X rays ECG’, bod tts oF oer special test performed {Have you undergone / ads any suri procedure? us hon was the surgery done ? 1 yes pease give present cinicalconition or deformity disability PART I: SYSTEMIC INFORMATION [A. Nervous System: ove you ever suffered suring from ay ofthe folowing condtions o undergone any surgery? Mes fplersy ]——Inacrania infections infestations [[] Migraine []_Recrren Headache [J Tansient Ischemic Back] Tinging Numboess [] Spinal dsorders[-] Any oto disordos 11 Yes! then please ve exact duration and preient condition along with the treatment dts 18 ivi Disorder: Asi Osorders 5] Depression] Personality Disordes 7] ‘ny other disorder C] 11% then please ge exact duration and present condition along with the reatment details Respiratory System: Have you ever steed / sulting frm any ofthe folowing conditions? Yes ‘nstma CZ] Blood in Sputum [] COPOY Bronciectass []Tuberculoss [] Other incon inestators [>] Any ate disocdes C] IE "¥e' then please Bue exact duration and present condion along wilh the treatment detls D. Cardiovascular & Greaaory Sito: Hove you eve suteredsutring rom any ofthe following condons or undergone any surge? ws Breathlessness / Dasmoea on exertion [7] Congerial dsese/Ssordors [-]Mypertersion (]__ schema Disease Infectious dscases[-] el Vena Faire. []_Peighoral Vascular Discases Pabtations Petpheral Gedema E) __ Rheumatic heat disease 7 Rheumatc fever Ty ether disorder 11 Yee then please sive exact duaton,and present condition along wih Te treatment dtas |E Urinary Sistem: Have you ever sullered/sulleing ram any ofthe fling conditions oF undergone any surge? ve 1 No) No 10] Benign Posi Hyertooh CZ] Congenital dfs 7] Inconinence of Urine [3] Plyrstc Kidneys [] Renal Uretie lei (J Rena atre Rotarent UNE] retina side 7] Any other disorder [] 11 Yes then please ge exact duration and present conditon along withthe treatment details ‘Anemia C]———Bledng Disorders] Thaassenias [] Any oer bood disorders) “lf. Nes then please kive exact durationand present condition along wih the treatment detailsG Musculoseltl System: ave you eve sufrestring fom any othe fing contin or undeeone any surgery ? ves[_] 1 no] ‘Gow nodesies [] elections He eteonels-] Injuries sails, Fraarshele on healed ] Ostoatiets [-] Osteoporosis] An ots disorder 2) 1s hen peae pe exact drat. and preset condo lon wi the wears & confit ar dsabilty /eloity —_ ave you eve fred suring rom any of he following codons o underane ay srt? ves] /n| Didbees CJ Hrpotwoidsm] _Hypertoiism 7) nid Disorder C] ‘ay ater disorder Wee then please give exact duraonand present condition along wth the teeter details j Nose, Tvoat & Eye: Have you ever led / suring om any of the allowing condos or underrane ay sagt ? ves] / no Dovned Nasal Septum [Dit in swalwing (] Recurrent Siusiis C]—— ahonio] Recurrent Ear infections [J Au thes dors Hes’ then please ve tact dutationand preset condi akong withthe treatment desis 1 Reproductive Sytem: Have you ever sled ling ror ay of the folowing conto or undergone ay sary ? ves] no] rast lures) poss (-] Menstrual disorder Fexcorthoes Ovarian ons tern bro] obs (-] iene prose] Pene dsuncion ‘ay ober dsrdess For Females: Are you peanant ot sresen ee thon please give exact durationand present condton along withthe Weatment deta Hae you eer sured rom odo you sles rom Canc or Tar of ay ind? ves] no Ys then please sve erat durationand present condo slong with he teabment details Have vou eve sured / llr Kom any of he fellowing condos o undertone ay srg ? ves[_] no] ed perc disordess []Cobis[7] Grobe diese] FeswesfistulaMemorhods [] Gal ladder disorders / Gall Sones 7) fiemia =] Hepaiay BCE Se C] Une curds C] iver ihoss 7] Oesophageal avesias CP Pancess [] Splenic orders) Aa ober asorder [] "es" den please sive exact duraionzand present condition Bong withthe treatment details 1M. General Systemic Spams: ave you eer sired / sling tom an oter eases dares not ted above? ves] /n| 11 ¥es' Gen lease give exact durationand present eondion along withthe treatment details one with treatment details =e Sot (0, Hove you ever sere / sling hom anya the flowing conor or undrzone any srgey? ves[_] /No| ‘edamay puliness []_Uncelined rcarent or ptt fever] Unexlsned weight oss C] oy skin disorders] Ay ther dearer 11s en please He erat durationand present condtion along withthe weatment deta —_ Hove yu ever sured sulering fom any enue wansited Bases? 11s hen please sve ead dorationand present condition along withthe teat details (Fam Histon: Have ou o an of your medi ay members (ater Mather / ther oS) have dad Cans, Har ck, iets, Hypertension, Caras disease, Suoke, or an other majo disse) ord? ves [7] /no| Was ror 10 60 ys ot ae? ‘ ves] /n| Habits: Alcohol C] Smolin 3) tobaco 5 obec pase J Aother EJ 11s then alae uve exact doration ad present condition slong with te tresbmentdetas Dedaration debe that the statervers made by mein hs Medal Examination form ae te and tothe esto my. nome and bei and | rb are that ths drain shal fon he basis ofthe contract Betveen me nd aj aon Gert laserance Coma Li. futher consent and atrie Bl liane General srance Conny Ld andor any of ts shored epesettes to seek medial ilormatin from any hospal/edicalpracioner who has attended or may aon in uur concering any disease oF Hess. | ace the above delratonstaterents made under Pesona istry and further fisdase that on The eve of finding anything cra Yo wha as ben deed by me, skal be held responsible for al consequences theca and insronce cmany shal inex no Babity under this insurance Date: Insure Si Doctors Sgnedict Examination Reort PARTI: MEDICAL EXAWINER' FINDING AND ASSESMENT Please answer each queston and where appropriate provide pariculars . You ae asked nto ge the preson tobe assured any information about the resus of your examination, 1 1a which way you have sted yoursel ofthe identity ofthe person examined? Tick whichever i Diver ticense [7] as ort en Cod Any ter Do you know the persan to be assured ? Hove you previously examined advised or treated the person to be assured ? 1s there anything unfavorable inthe appearance or development of the person to be assured ? ‘yes, please specity a: Do you consider the musculo ~ shell system tobe hey? Do you consider the tin and mucous membrane to be het? Do you consider the respatory system fo be heat? Do you consider the tet, gue, out ad oat be hay? Do You consider the digs system to behest? 's there evidence of Cadac Iypertrorhy? ‘We the heart sounds normal? ‘re there any murmurs? Iso pease describ them in detail, including sit, timing, intensity and transmission, ‘Ns indicate the effect of posture or respiration Height in Gm _ as Weight in Ke ‘Chest measorerent in cm (isp f exp) Git of abdomen at umbilicus ( on) Blood Pressure Reading in mm He ( Systoic Diastolic) Sis Pease provide the further readings at 10 minute interval if the Gist reading exceeds 10 90 : 3 the pulse normal in character? Pulse Rate. Ent, Nose, Throat Eraminations Per Asdomen Exainaion 1s thery any abnormality of the abdomen, ver or sper on inspection, palpation or percussion ? Try, please provide the details Do you consider the urinary system and gent organs to be heck? Urine Anais ‘Abin Sigs” (the posite / abnormal indngs (Pease specify) Pease aac a copy of the report of rine nasi Yes 1%) 1no[_] 1%) L] 1%| 1%] 1mo| 1No| 19 1)18 ECG nding 2 ee ECG Reporting __ 19, Are there any other abnormal findings not indicated above W yes, please provide the details 20 Does the person to be assured have/ had any past history which may increase the sk of HIV infection? 21 there any fur evidence, medical or otherwise which you think shouldbe obtained in oder to asses the person i be fi for health insurance? ‘indy specity Signature of the Medical Examiner Qualification eR HELATHIUN 2013,