MEDICAL EXAMINATION REPORT

THE FOLLOWING QUESTIONS ARE TO ASKED AND RECORDED BY THE EXAMINER

Full Name of Proposed Insured :

Date of Birth : __________________

Proof of Identity ( Please check ) :

Identity Card No. ____________________________

Passport No : _____________________

Driving License No. __________________________

Others : _________________________

1. (a) When did you last consult a physician ? ____________________________________________________________________________

(b) Please state reason for consultation : ______________________________________________________________________________
( c ) What treatment, if any, was prescribed : ____________________________________________________________________________
(d) Please state name and address of physician : ________________________________________________________________________
2. Have you ever been treated for or ever had any known indications of :
( CIRCLE APPLICABLE ITEMS )
(a) Disease or disorder of eyes, ears, nose or throat ?

7.
Yes

No

(b) Dizziness, fainting, convulsions, headache, speech defect,

paralysis or stroke, mental or nervous disease or disorder ?

Family History :
Tuberculosis, diabetes
cancer, high blood pressure
heart or kidney disease
mental illness of suicide?

Shortness of breath, persistent hourseness or cough, blood

spitting, bronchitis, pleurisy, asthma, emphysema, tuberculosis
or chronic respiratory or lung disease?

Age
if living

(d) Chest pain, palpitation, highblood pressure, rheumatic fever,

heart murmur, heart attack or other disease of the heart or
blood vessels?

Yes

No

State of Health/ Age at

cause of death? Death

Father

(e) Jaundice, intestinal bleeding, ulcer, hernia, appendicitis, colitis,

diverticulitis, hermorrhoids, recurrent indigesion or other disease
of the stomach, intetines, liver or gallbladder?

Mother

(f) Sugar, albumin, blood or pus in urine, venereal disease, stone

or other disease of kidney, bladder, prostate or reproductive
organs?
Brothers
(g) Diabetes, thyroid or other endocrine disease?
(h) Neuritis, sciatica, rheumatism, arthritis, gout or disease
or disorder of the muscles or bones, including the spine,
back or joints?

Sisters

(I) Deformity, lameness or amputation ?

(j) Disease of skin, lymph glands, cyst, tumor or cancer?
Children
(k) Allergies, anemia or other disease of the blood?
3. Are you now under observation or taking treatment or medication
for any disease of disorder?

Number Living : _______________________

4. Have you had any change in wright in the past year?

Number Dead : _______________________

5. Have you within the past 5 years :

(a) Had any mental or physical disease or disorder not listed above
(b) Had a check-up, consultation, illness, injury or surgery?

8.

Females Only :

(d) Had electrocardiogram, X-ray, other diagnostic test?

(a) Have you had any

disorder or
manstruation,
pregnancy or of the
female organs
or breasts?

(e) been advised to have any diagnostic test, hospitalization or

surgery which was not completed?

(b) Are you now Pregnant

( c ) Bveen a patient in a hospital, clinic, sanatorium or other medical

facility?

Yes

No

Yes

No

(if yes, how many months)

6. Please state current consumptions of

Any Additional Information :
Tobacco : _________ day / week

Alcohol : ________________ day / week

____________________________________

If you do not smoke cigarettes now but did so previously, when did stop ?
____________________________________________________________________

____________________________________

DECLARATION
I declare that I am the person named as the proposed insured and that the above statements and answers are true and complete to the
best of my knowledge and belief. I confirm that they are correctly recorded and are a continuation of and form a part of the application
on my life to Al Sagr National Insurance Company.
Signed at : _______________________________________

Signature of Proposed Insured : ___________________________________

on this ______ day of ______________________ 20______

Signature of Medical Examiner : ___________________________________

Please send this report promptly to Al Sagr National Insurance Company

MEDICAL EXAMINATION REPORT ( continued )

THE FOLLOWING QUESTIONS ARE TO ASKED AND RECORDED BY THE EXAMINER
Full Name of Proposed Insured :

Date of Birth : __________________

INSTRUCTIONS TO THE MEDICAL EXAMINER

When an Examination is begun the report thereof becomes the property of the company and must not be suppressed of destroyed
regardless of your recommendations and regardless of whethere the proposed insured or any other person offers to pay the
medical fee in order to avoid a declination.
An Examiner is not permitted to examine his own patients or relative or applicants of an agent who is a relative.
Any erasures or alternations in your report must be initialed by you.

1.

2.
3.
4.

Both the statement of the proposed insured on the reverse side and the medical examiner's report must be recorded in your handwriting.

MEDICAL EXAMINER'S CONFIDENTIAL REPORT

How long have you know the proposed insured ? Years ________ Months _________. Are you related ? _________________________

9. (a)

Height

Weight

Chest

Chest

Abdomen

(in shoes)

(clothed)

(Full Inspiration)

(Forced Expiration)

at Umbilicus

cms

Kilos

(b) Did you weigh?

cms
Yes

Please record 3 readings taken at intervals of atleast

5 minutes in either of the following circumstances.
cms
(a) First reading is over 140 systolic or 90 diastolic
or (b) There is a history of hypertension.
No
1
2
3
No
Systolic
( 4th Plase )

cms

No Did you measure?

Yes

( c ) Is appearance unhealthy or older than stated age ?

10. Blood Pressure

Yes

11. Pulse
Please exercise sufficiently to increase rate by atleast 25 beats per minute
after exercise.
At Rest
After Exercise
3 Minutes Later
Rate

(Change of
sound )

Diastolic
( 5th Plase )
(Disappearance
of sound )

Irregularities
per minute

* if applicant discloses a history of treated

hypertension, please complete hypertension questionnaire

12. Heart
Enlargement

Yes

No

Dyspnea

Yes

No

Murmur (s)

Yes

No

Edema

Yes

No

If the answer to any question is "Yes", identity

question number and list complete details.

(describe below - if more than one, describe separately)

1

Indicate:

Location

Constant
Inconstant
Transmitted

Apex by
Murmur area by
point of greatest
intensity by

Localized
Systolic
Diastolic

Transmission by

Please comment and give your impression?

Soft (Gr 1-2)

Mod. (Gr 3-4)
Loud (Gr. 5-6)
After Excecise
Increased
Absent
Unchanged
Decreased
* If there is history of coronary artery disease, please complete CAD
Questionnaire
DECLARATION
I declare that I am the person named as the proposed insured and that the above statements and answers are true and complete to the
best of my knowledge and belief. I confirm that they are correctly recorded and are a continuation of and form a part of the application
on my life to Al Sagr National Insurance Company.
Signed at : _______________________________________

Signature of Proposed Insured : ___________________________________

on this ______ day of ______________________ 20______

Signature of Medical Examiner : ___________________________________

Please send this report promptly to Al Sagr National Insurance Company

MEDICAL EXAMINATION REPORT ( continued )

THE FOLLOWING QUESTIONS ARE TO ASKED AND RECORDED BY THE EXAMINER
Full Name of Proposed Insured :

1.

2.
3.
4.

Date of Birth : __________________

INSTRUCTIONS TO THE MEDICAL EXAMINER

When an Examination is begun the report thereof becomes the property of the company and must not be suppressed of destroyed
regardless of your recommendations and regardless of whethere the proposed insured or any other person offers to pay the
medical fee in order to avoid a declination.
An Examiner is not permitted to examine his own patients or relative or applicants of an agent who is a relative.
Any erasures or alternations in your report must be initialed by you.
Both the statement of the proposed insured on the reverse side and the medical examiner's report must be recorded in your handwriting.

MEDICAL EXAMINER'S CONFIDENTIAL REPORT ( continued)

13. Is there on examination any abnormality of the following:

(circle applicable items and give details)

Yes

No

If the answer to any question is "Yes", identity

question number and list complete details.

(a) Eyes, ears, nose, mouth, pharynx ?

( if vision or hearing markedly impaired, incidate degree
and correction ).
(b) Skin : Lymph nodes : vericose veins or peripheral arteries?
( c ) Nervous system (indicate reflexes, gait, paralysis )?
(d) Respiratory System ?
(e) Abdominal Organs ( indicate scars )?
(f) Genitourinary system ?
(g) Endocrine system (include thyroid and breasts)?
(h) Musculoskeletal system (include spine, joints,
amputations, deformities)?
14. Are there any hernias?
15. Are you aware of additional medical history?
( a confidential report may be sent to the medical director )
16. Urinalysis

Specific Gravity

Albumin

Sugar

In addition to your urinalysis, please arrange to microscopic analysis at

a qualified laboratory in the following circumstances:
(a) If requested by the company
(b) Any urinary abnormality is found or suspected, In the case of
albuminuria please arrange for applicant to produce a second early
morning specimen.
( c ) There is a history of hypertension, kidney, prostate, bladder or
geniro-urinary disease within the last two years.

17. Do you know or suspect anything adverse about

the proposed insured's health, character,
mentality, habits or morals not otherwise
covered above ?
Yes
No
( a confidential report may be sent to the
medical director )
_______________________________________
_______________________________________
_______________________________________

If the answer to any question is "Yes", identity question number and list complete details :

DECLARATION
I declare that I am the person named as the proposed insured and that the above statements and answers are true and complete to the
best of my knowledge and belief. I confirm that they are correctly recorded and are a continuation of and form a part of the application
on my life to Al Sagr National Insurance Company.
Signed at : _______________________________________

Signature of Proposed Insured : ___________________________________

on this ______ day of ______________________ 20______

Signature of Medical Examiner : ___________________________________

Please send this report promptly to Al Sagr National Insurance Company