Beruflich Dokumente
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11601117
Confidential Medical Certificate – SEVERE ASTHMA
(To be completed by the Attending Physician )
The abovenamed is insured with Prudential Assurance Malaysia Berhad against happening of certain contingent events associated
with his/her health. A claim has been submitted in connection with SEVERE ASTHMA, and to enable us to assess the claim,
we would be grateful for your co-operation in the completion of this form.
In order for the claim to be valid the following definition must be fulfilled:
(1) An acute attack of Severe Asthma leading to admission to hospital and mechanical ventilation for a continuous
period of at least four (4) hours to establish control of the asthma attack on the advice of a consultant pediatrician;
or
(2) At least three (3) of the following features of chronic, severe asthma:
Continuous daily usage of oral corticosteroids for a minimum period of six (6) months on the advice of a
consultant pediatrician to control the child’s asthma; or
Significant growth impairment attributed by a consultant pediatrician to the child’s asthma (which is for
this purpose defined as a height below the third percentile for the child’s age and sex in a child with
asthma whose height has previously been recorded at or above the fifth percentile at a routine
developmental examination at the age of at least one (1) year); or
Significant and persistent limitation of the peak expiratory flow rate (which is for this purpose defined as
maximum peak expiratory flow rate recordings of less than eighty percent (80%) of the rate predicted
for child of the same age, sex and build while taking the treatment prescribed by a consultant
pediatrician for asthma). The recordings are to be made by a consultant pediatrician on at least four (4)
occasions at intervals of no less than one (1) month in a period of at least twelve (12) months. The
pediatrician certifying the recordings should be satisfied that the child is complying with optimal
prescribed asthma medication throughout the period to which the recordings relates.
Part A: General
1. Are you the patient’s usual medical
attendant?
Details of diagnosis :
Yes No
If yes, please provide details in the corresponding table whether the patient was placed on a mechanical ventilator machine during
admission to the hospital :
Date of Date of Name and Address of Mechanical Period ( Hours) on Was the period
Admission Discharge Hospital Ventilation Mechanical Ventilation continuous?
Required?
15. Please provide details of all other investigations performed and treatment prescribed.
If yes, please give details including nature of condition, Nature of Date of Onset Treatment Current Status
date of onset, treatment received and current status of Condition Received of Condition
the condition
Age of Onset :
20. Please provide the names, addresses and qualifications of all doctors, hospitals or clinics the patient has been referred or
attended to for this condition
Name Qualification Address of Doctor / Clinic/ Hospital
I hereby certify that the above answers are all true and to the best of my knowledge
Signature
Name
Professional qualification
Official stamp