PERSONAL ACCIDENTs / ACCIDENT MEDICAL REIMBURSEMENTs ATTENDING PHYSICIANS STATEMENT

(To be filled by the attending physician who treated the patient)

KINDLY USE EXTRA PAGE OF PAPER WHERE SPACE PROVIDED IS NOT SUFFICIENT FOR YOUR REPORTING

1. Patients Name:

2. IC No.: 3. Age :

4. Occupation : 5. Nature of occupational duties:

6. Date of Accident as related by the patient: Time:

7. Date of First Consultation: Time:

8. Describe in detail the nature of accident as related to you by the patient:

9. Were there any external and visible injuries or wounds as a result of this accident? Yes No

a) If yes, then please describe the extent of injuries including site and other characteristics or features as seen by you.

b) If no, please describe any other evidence that is consistent with the accident as claimed by the patient

c) In the event of any amputation, please state at what level (eg: proximal, middle, distal) You may use the diagram in page 3 to illustrate the
level of amputation and percentage of loss.

10. a) Based on your professional opinion, are the patients current bodily injury (ies) consistent with the description / nature of the accident ?

Yes No

b) If not, are they traceable to any pre-existing condition, previous injuries not related to this accident or any other cause known to you (Please
specify)

11. a) Is the patient now, or was he/she at the time of the accident suffering from any illness, disease or infirmity/ physical deformity/intoxication?
Yes No

b) If yes, please state the nature and to what extent his/her recovery has been or may be retarded thereby.

12. Was any X-ray or any other investigatory tests taken? Yes No

(If yes, please supply a copy of the Radiologist or related reports for our reference)
_________________________________________________________________________________________________________________________
13. What is the final diagnosis of the patient upon your clinical findings and / or investigating tests results

Form ID
11601004
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14. Details of injuries and all treatment prescribed. Please include the following information ( where applicable )

a) Number of Stitches :
Date of Removal of Stitches:

b) Type of Dressing:

c) If patient was put on any form of immobilization (POP, backslab, crepe bandage, etc), please furnish us the following :
i. Date First Applied:
Date of Removal:

ii. Date Started Physiotherapy:

Date of Completion:

iii. Date Started Full Weight Bearing:

Date of Completion:

iv. Details of Limitation of Movements on any joints (please specify):

d) Treatment given including follow-ups:

Date of Details/Conditions of Details of Treatment Details of limitation / Details of Healing

Consultation Physical Injuries ( Eg Dressing, Incision and physical disability (eg. Progress
Drainage, Medication Range of movement,
Prescribed, etc ) condition of wound, etc )

1.

2.

3.

4.

5.

6.

7.

8.
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e) Please illustrate the injuries in the following diagrams

15. (a) Date of Last Consultation:

(b) Condition of the injured part(s):

16. Was the healing (Straight forward / Complicated)? Straight forward Complicated

If complicated, please provide details of complication/s.

_________________________________________________________________________________________________________________________

17. Details of Hospitalisation (if any):

a) Name of Hospital:

b) Admission No:

c) Date Admitted: Date Discharged:

d) Date of Surgery Performed:

e) Type of Surgery Performed:

18. Name and address of other doctors who treated the patient for the same injury, and the date of treatment

19. For Females Only:

(a) Was the patient pregnant at the time of accident?
If yes, for how many weeks /months?

(b) Was the accident caused directly or indirectly by the pregnancy? If yes, please describe in detail.

I hereby certify that (Please choose one of the following )

I am the patients attending physician and I have personally examined and treated the patient for his/her injuries described above /
I have personally perused the patient's medical records
and that the facts as stated above are all true to the best of my knowledge and information.

If you are not the attending physician, please state :

a ) The Attending Physicians Name : ____________________
b ) Kindly state the reason(s)for completing the above mentioned information on behalf of the Attending Physician :
_________________________________________________________________________________

..
Signature of Attending Physician Name & Practice Stamp Name & Address of Hospital/Clinic

Date : .. Telephone No. :

Note to Doctor : Please return this report in a sealed envelope with an official practice / clinic / hospital stamp.
Thank you.

Prudential Assurance Malaysia Berhad (107655-U)

Level 17, Menara Prudential, No. 10, Jalan Sultan Ismail, 50200 Kuala Lumpur. P.O. Box 10025.
Tel : 603-20318228 Fax : 603-2032 3939