Star Health an{ Allied lnsurance Co. Ltd.

MEDICAL EXAMINATION REPORT

(To be filled tu by the Medical Exsminer)
Nanc of thc Frson to
be insured:

Sexl

Mrit{l

Slatus:

IdcnlificatnD

Ma*s:(l)

(2)

l- \'leasrremeni & Vit'ah

Weieht (Xqs)

BP

Slstolic

Diastolic

PulseRate

I Readjng:
ITI

Readin!:

*1fthe Systolic rcading is 140 ortnorc orDiastolic reading is 90 ormore, secondand third reading shorld bc t.tkcD $,iih minutes intenal ofresr
2.( a) Famil)

l0

Histor]: Parenis
U alive

IfNOT alive
Age at

Prcscnt Health Status

CauseofDath

(b) Famil"v Histor]: Diseass ofp:rrnts

Wlether any one has suffered or is suffering liotn any ofthe followinr

diseases, give delails

Relationship ofthe person ( l.ho is

Di$ase

Detrils

sufTring ) rvith the person to be

Stoke(Parahsisl
Hearl Disease

Ofiers ( SDccif,,

3. Personat Physician / Last Consultation:

Name and address of the personat ph.l sicirn ofthe person to b insurcd (if non, stat th name ofthe doctor last consulted)

Datc of last

4. (a) Whethr the persor to be insured is sufiering

fron any of th folloiring

diseases, qive details

DISEASE

DETAILS

H}?etension
Strokc(paralysis) Heart Disasc
Renal Complications

often ( spcciS' ) (b) In thc past 1 or 2 or 3 or 4 ycar(s),

Ifyes, sive detailsi

had he/she takcn X-ray. TMT,CT ScanlLing. MRI. Ulhasonosraphy, ECG, Blood and Urine tests or ofter diagnostic tests such as ELISA, Australia antigen tesi etc ?

(c) Details ofillness for which OP treatment,IP treatment taken or any check up donc durjng last one yed.

E$minatior of systEms
SYSTEIITS

\TS
cinj. nose or throat?

NO

Df,TAILS

f,YES & ENT

Is drcre

my evidence ofpasr or prcsent

disease of eyes.

Has hdshe undergone tonsillitis opoation?

Anv evidence olcatarict or cataractoLher eve oneEtion underqonel

Are there any nnssing leeth? lf so, how n1!lry?

RspiratorJ Systm. Are therc any slmproms or signs suggesting abnomrality or disease of rhe resDiratoF svstem. evidence ofBronchial Asthfra or Trhtrdrlosi er.? Cardiovascular System (a) Does th hean sound nomal? Is anv munnurDresenn
O) Aie the pcripheral pulses nor,nal? (c) DctaiLs of sugery rmdergone,

ifany

Is there any evidence ofenlargement of liver or sDleen?

T\ there e! idenc

olpllcsor fistulal

Any abnomal mass palDable/tendemess SuEical Scar

Hydrocele Chronic LllceN

Enlfgement ofPmstale Any Mass lesion Any other opmtion undersone

SYSTBNIS Nervous Systems

YtrS

NO

DETATI,S

h fiere
Genito

any evidence ofnen or$ discasc, such as paralysis, epilepsy, wasiine. tremor. jnvoluntary movenents, etc?

- Urin!ry

System

ls ilere any cvidence ofpast veneral disease? ls ieslis nomml in location, size and consistency? pleasc glvc delails?

rany abnomalines presen!

Dtails of accident. Is $ere evidcnce ofany operation or inju.ry due to accidenf

ifves. Dleasc indicate the extent ofdisahleme.r For female only Is thdt ary disease ofihebrcasls? ( Lu p, any Mass lcsion )
Is therc any evidence ofpresmrct ? Do you suspecl any dis.-ase ofuterus, cewix or ovadcs? Is there any surgical fealures related io childbirth or miscarriage?

Medical Eraminer's Opinion

Are there any Pre'Existing diseases?

lf

yes , give details

'

ls the per,on ro be ir,u cJ, -eldred or kno$ , ro Medical I

\aminer.

es

\o

Signature of the person to b insured. '

Nrme ofthe Medical Examiner. Signrtur & seal.

Date:

To

befi

edin by the CompanyJs doctor,lPanel doctor

Details ofpre-exjsting diseases ofthe person to be insured to be incorporated in the policy:-

(1) (2\ (3)

Nsrne of doctor:

Signsture and Seal:

Place:

Date:

4 \tedic!l Ir!min!iion in
rorpcfons *nh advese lvledical Hislory
and aged

respect otHalrh Policics:

50 yelrs.

tr.Il.sals abole

colense h subiect {o the lollosins erarnrnotions

IlowevcriorSenrorcrri,e. ed Supersqrlus policics this nrdical c{annral

n nor conpulsor,.

I E E D E
of

lor SunInsnEd

upto Rs.

I lac

Ceneral Medical Exomnradon

F,stinsBlood susa
Unne exmnradotr for Albumnr,' Susar

EcC

cardnlosist (h
quali licaiion

&

Cardiac Evalualion Repor.

cose of

fron 0

qralified MD

nonllailabilil

I For Sun lnsuGd uplo Rs. I lac E cd.nl Medioal lxahinaton O Fasliag Blood Sugar E Unne exaniindton lDralbumi. / Susar O lCG & cardiac Eraluarion ReFn fti. ! 2 O O Q E
lior
Sum Insuied abovc

quaMed

quali,ied Crrdrologi$. a Fa.licins

nar

be

Crdiolosist th

Rs

la. lnd

uDlo Rs.

appDacbed)

F.$ing Bl.odSugar
UrnE cxxnimti.n

ure.

Gynac.ologisr (MD/DCo)

'ar

J',o".

dc .-arJ,r.. oo.e,ri

br Albunlin

/ Sugar a

2. lorSnn lrNucdabolc Rs. I Lac Q Ceneral Mcdical Exarninarion O rdtins Blood Surai D ru e +!n nB on 'or qlbrnn \' sr E| lcc & cardiac lLairari.n Repod lon a qua|fied Cddiolosisl (ln cxse.l non avnihbilily .rqualited Cadioloeist. 3 pra.licing Cardnnosisl rvrth MD qualitcalion nay be E
?eNic

LCC

&

cardiac E aLuarion Retorl liorn

'lEad l4il1 no lrcad nill rcsi ior !.*ons abole 60 ye{s of

r ,o \, r tr,i. Q C e!.ral M.d i.al rxaninx rio.

Q
Unne erddnalion for albnnin i Sugar

ljlra s.und

scan

O ECG

&

Cediac Evatuation Rep.n

Mill Gnbjcd to thc opinion or

non !
arc.

qualified

Tread r c.'d

ni

rc.

L'F ^ .,D,

e,0)ear

the CBrdioloEisl

l,

no

> > .

\heE

the trCC is abnomal Echo can be insiste{l at Insured\ cost to be doubLy clear atont tnc risk. ln casc ofdonbl we can asl the Insurtd to himself/hesellfornedical eam.

loi d, l:. r, 'eq'eq o reJ.al ,.' '

I4prl!9!!-c!.s!.950-r93!!

i.,er.JooEsirhPHOlOor l

lre-Mdicnl Exnninrtion for Siar Critictrc Polis

For persons upto 50 vears

(a)

Forall sum insued

G)

for sur insuEd olRs.2la.s:

NO medi.alcrsminrrl.n

Usual Medical exminarion ap!1ica61e lin lvledicla$ic plus Serun Creatinine and Micro Albuminnre!.
(b )

Ior sun insucd ontions .l

dbove Rs 2 lscs

al nedical exanrinalion applicable for abolc 50 yca^ tlus Sdrun Cre,tirine rnd Micrn Alhnninnr.n