PT.

Asuransi Allianz Life Indonesia

MEDICAL CERTIFICATE
Application Form No. : _______________________ Name of prospective insured Branch Code : ___________________

: ..

Birth date of the prospective insured : ID/Driving License : ...... Each question has to be answered with No or Yes by the physician and explained, if answered with Yes in Part I or No in Part II Part I. Declaration before the physician Please put the following questions to the prospective Insured before carrying out your examination 1. Do you or did you suffer from diseases, disorders or complaints : a) of heart or circulatory organs, e.g. heart defect, cardiac insufficiency, shortness of breath on exertion, cardiovascular circulatory disorder, oppression or pain in the cardiac region, cardiac infarction, heart hammering, high blood pressure, stroke, other circulatory disorders, phlebitis, embolism ? b) c) d) of the respiratory organs, e.g. tuberculosis, pleurisy, repeated or chronic bronchitis, asthma ? of the digestive organs, e.g. gastritis, stomach or duodenal ulcer, stomach or intestinal hemorrhage, liver disorder, jaundice, gall bladder disorder, diseases of the pancreas ? of the urinary or reproductive organs, e.g. inflammation of the kidney, renal colics, stones, cystic kidneys inflammation in the renal pelvis or bladder, diseases of prostate gland, difficulties or pain when urinating, blood in the urine, excretion of albumen ? of the brain or spinal fluid, the nerves, e.g. mental disorders, depressions, epilepsy, convulsion, paralysis, fainting fits, giddiness, frequent headaches ? the eyes, e.g. impairment of vision ? Do you wear glasses or contact lenses ? Is the impairment hereby completely compensated ? of the ears, e.g. discharge from the ear, deafness ? Do you wear a hearing aid ? Is the deafness compensated with this aid ? the skin, the glands, the spleen, the blood and allergies ? diabetes, high cholesterol values, high uric acid values, gout, thyroid dysfunction ? tumors Have you ever been treated with chemo-therapy or Radio-therapy ? the bones and joints, the spine, the intervertebral disks, rheumatism of the joints, rheumatic complaints ? acute or chronic infectious diseases, veneral diseases, tropical diseases, e.g. Malaria ? Has an AIDS infection ever been diagnosed ? (e.g. blood test) No Yes If Yes give the information about the diseases, how long and name of the doctors

e) f)

g)

h) i) j) k) l) m)

2. a) Have you ever been treated with medicines, e.g. cardiac stimulants, are you taking blood-sugar or blood pressure reducing drugs ? Which ? b) c) d) e) 3. a) Which medicines do you presently take ? Have you taken or do you take sedatives or drugs ? Which ? When ? Have you ever been or are you at present advised or treated as a consequence of excessive alcohol consumption ? Have you suffered from toxicopathy ? What kind ? Any sequels ? Have you had accidents, injuries or suffered poisoning of any kind ? If so, what kind ? Any sequels ?

b) Have you ever made an attempt to commit suicide ? When ? 4. Have you ever undergone an operation or is an operation pending ? 5. Have health impairments or injuries impaired you general health or your ability to work ? If so, which ? I hereby declare that the above statements are true and complete and agree that this questionnaire, together with the proposal dated Shall form the basis of the contract between myself and PT. Asuransi Allianz Life Indonesia. __________________________

Date : ________________________ signature of prospective Insured : __________________________ Stamp & signature of Physician : _______________________

PT. Asuransi Allianz Life Indonesia

Part II. Result of Medical Examination No Have you already performed a medical examination on, advised or treated this person ? If so, when and why ? 1. a) weight without clothing : ___________ kg Neck circumference : ___________________ cm Height without shoes : ___________ cm Waist circumference : ___________________ cm Chest circumference when breathing in : _________________ cm Trunk circumference : ___________________ cm b) How is the general and nutritional condition of the person to be insured ? 2. 3. 4. 5. Do you consider the skeleton and locomotor system healthy ? If not, what disorder is present ? which dysfunction is present ? Do you consider the skin and mucous membranes healthy ? if not, what disorder is present ? Do you consider the sensory organs healthy ? If not, what disorder is present ? Do you consider the nervous system and psyche health in particular are reflexes (pupillary reflex, knee-jerk and Achilles heal reflex, plantar response and abdominal reflex, Romberg) normal ? If not, what abnormalities are present ? Do you consider the hormone system particularly the thyroid gland healthy ? If not, what disorder is present ? Heart and circulatory system a) Are the heart sounds clear and normal ? b) Are there any murmurs ? Which ? Where ? c) Are the murmurs organic ? d) Pulse rate and blood pressure : Yes If No in question 1-13 give more details

6. 7.

Pulse rate per min. Resting ____________

Blood pressure in mm Hg. Syst. Diast. _____________ _____________ ______________ ______________

Control after 5 minutes ____________

e) is the pulse even and regular when resting and after stress ? Circumference of upper arm (in obese patients) ____________ cm If not, what abnormalities are present ? With extra systoles : how many per minutes resting & after stress? f) Are there insufficiency or decompensation symptoms ? (shortness of breath, cyanosis, edemas) g) Are Varicose veins present ? (intensity, extent, ulcerations, scars) h) Nature of peripheral pulses, foot pulse in particular ? 8. Respiratory organs a) Is there hoarseness ? Cough ? Since when ? Cause ? b) Form and curvature of the chest ? c) Findings by auscultation and percussion d) Do you consider the respiratory organs healthy ? If not, what disorders are present ? 9. Digestive organs a) Pathological findings on the tongue, tonsils, pharynx ? b) Results of inspection, palpation and percussion of the abdomen : (stomach, liver, gall bladder, pancreas, spleen, intestines) c) Do you consider the digestive organs healthy ? If not, what disorder is present ? 10. Urinary and reproductive organs a) Urinalysis : Was the urine passed in your surgery ? Yes No Does it contain : Excess protein _________________ Sugar ______________ Blood _____________ Bilirubin _________________ Urobilinogen ______________ Cetone _____________ Leuco _________________ Other ______________ Sediment analysis (upon pathological findings in strip tests) b) Do you consider the urinary and reproductive organs healthy ? if not, what disorder is present ? 11. Miscellaneous : What other pathological findings are present which have not yet been mentioned (e.g. swollen glands) Which ? 12. Blood test : Was blood taken in fasting condition ? Yes No Unit Normal value Cholesterol Creatinine 13. Triglyceride Gamma-GT

Unit

Normal value

If any pathological findings are present, which findings have you informed the examined person of ? Please enclose findings and examination reports, including those hospitals, health cure institutions and specialists etc. Upon examination, these documents will be returned to you immediately. Place and date _____________________________________ Stamp & signature of Physician _______________________________

PT. Asuransi Allianz Life Indonesia