MEDICAL EXAMINER’S REPORT Form No LIC03-001(Revised 2020 Branch Code: Proposal/Policy No: MSP Name/Code: Date of Examination: Medical Diary No & Page No: Mobile No of Proposer/Life Assured: Identity Proof Type & No: Full Name of Life to be Assured: Date of Birth / Age / Gender: MaleFemaleOther Height / Weight: Pulse / BP (2 Readings): Medical History Questions 5. Any treatment/medication/surgery/hospitalisation in last 5 years? 6. Any X-ray/CT/MRI/ECG/Blood tests advised in last 5 years? 7. Covid-19 history/symptoms/treatment details. 8. Hypertension, diabetes, thyroid or weight changes? 9. Heart issues, high cholesterol, surgeries? 10. Kidney related disorders? 11. Liver/lung/respiratory disorders? 12. Blood or circulatory disorders? 13. Cancer/tumor/cyst history? 14. Epilepsy, stroke, paralysis, neurological issues? 15. Disabilities, joint/bone issues, arthritis? 16. Digestive/stomach disorders, hernia, ulcer, piles? 17. Mental health issues or treatments? 18. Abnormalities of eyes, ears, nose, throat, mouth? 19. HIV/AIDS/STD test results or treatment? 20. Other conditions, smoking, alcohol, drugs? For Female Proposers Only Pregnant? If yes, duration: Pregnancy complications / gynecological history: Declaration: You, Mr/Ms ____ declare that you have fully understood the questions asked to you during the call/Physical Examination and have furnished complete, true and accurate information. "I confirm the above declaration is true."
