PRUessential Child

11601117
Confidential Medical Certificate – SEVERE ASTHMA
(To be completed by the Attending Physician )

Name of Patient Policy No

Date of birth Identity Card No.

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:

“Severe Asthma” means asthma evidenced by EITHER:

(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

 The presence of a Harrison’s sulcus chest deformity as confirmed by a consultant pediatrician; 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?

2. If yes, over what period do your records

extend?
a) 1st consultation (dd/mm/yyyy) a) ________________________

b) Last consultation (dd/mm/yyyy) b) ________________________

3. Please provide details of the height and Date Height ( cm ) Weight ( kg )

weight of the patient ( Note : Please include
details of Age 1 to current )

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4. What were the symptoms presented when Symptoms Duration of Symptoms
you first attended to the patient? And how
long had the symptoms been present when you
first saw the patient?

5. Has the patient previously suffered from the

condition specified above or any possible
Yes No
related illness?

If ‘yes’, please give dates of consultations and

the resulting diagnosis Dates of Diagnosis
Consultation

6. Has the child missed anytime off work or Yes No

school due to this condition and for which
medical certificates were provided?

7. Please provide full and exact details of the Date of diagnosis :

diagnosis of Severe Asthma

Details of diagnosis :

Details on how diagnosis was made :

8. On which date did the patient and parent of a ) Patient

patient first became aware of the diagnosis?
b ) Parent of Patient

9. Is the condition acute or chronic?

10. Was the patient admitted for asthma attack?

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?

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11. Is the patient on continuous daily usage of Yes No
oral corticosteroids to control asthma?
If ‘Yes’, how long has the patient been on oral corticosteroids?

12. Does the patient exhibit Harrison’s sulcus

chest deformity resulting from the asthma?

13. Was pulmonary function test done on the Yes No

patient?
If yes, please provide details of all recordings of the patient’s peak expiratory
flow rate below. The recordings must be made on at least 4 occasions at intervals
of no less than 1 month in a period of at least 12 months.

Date of Maximum peak Predicted rate for a Type of treatment

recording expiratory flow child of the same age, prescribed
rate sex and build?

14. Was the patient complying with optimal Yes No

prescribed asthma medication throughout the
period of these recordings? Please state the medication used.

15. Please provide details of all other investigations performed and treatment prescribed.

Date Nature of Complaints Investigations Performed Treatment Prescribed

Please attach a copy of the laboratory/Histology investigation results.

16. Was HIV antibody test done?

If yes, please provide dates and results of all HIV Yes No
antibody tests done. Please also attach copies of all Date Results of Tests Done
relevant laboratory reports

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17. Has the patient previously suffered from any
respiratory symptoms, or the condition specified above Yes No
or any possible related illness?
If ‘yes’, please give dates of consultations and the resulting diagnosis

Date of Consultation Diagnosis

18. Does the patient have any personal history of any

other major medical or psychiatric condition? Yes No

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

19. Does the patient have any family history of any

major medical condition? Yes No

If yes, please provide details including relationship to Relationship to Patient :

patient, nature of condition and age of onset.
Nature of 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

21. If there is any further information which, in your

opinion, will assist the Company in assessing the claim,
please give details.

I hereby certify that the above answers are all true and to the best of my knowledge

Signature

Name

Professional qualification

Official stamp

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