UNITED INDIA INSURANCE CO, LTD. Regd & Head Ofice United India House 24, Whites Road, Chennai - 600 014, CONFIDENTIAL Ret. No... PERSONAL STATEMENT REGARDING HEALTH Name in full (Block Capital Letters) ... 2. Father's Name in full. 3. Date of birth and age .... . Months 4, Matital status : (Martied / Single) . snvee Children. Daughters (In the case of female, following particulars be furnished) () Husband's full Name .. (i) His occupation 5. Have you lived during the last three years with any Person suffering from tuberculosis, leprosy or any other infectious disease? If so, give ¢etails. 6. What has been your usual state of health? Do you suffer from mental disability at any time? 7. Do you have any bodily defect or deformity? I so, please give details. 8 Have you consulted a medical practitioner within . the last two years? Iso, give details : 9. Have you been successfully vaccinated against small-pox? If so, when were you last vaccinated? 10. Have you ever suffared from any of the following Answer'YES': If yes, the no. of ailments : or'NO' : attacks, dates and duration (a) Giddiness, fits, neurasthenia, neuralgia, paralysis, § <———"“" _ insanity, nervous breakdown or any other disease of brain or of the nervous system? (0) Persistent cough, asthma, pneumonia, pleurisy, spitting of blood, tuberculosis or any other affection of lungs?. (©) Fainting atiacks, chest pain, breathlessness, palpitation or any other disease of the heart? (d) Sprue juaundice, anemia, piles, dysentry, cholera, abdominal pain, appendicitis, or any other disease of the stomach, liver, spleen or intestines? (0) Any skin eruption? (| Heria, hydrocele varicocle, fistula or varicose veins (g) Any affection of kidney or bladder, dropsy, rheumatism, gout, gonorrhoea, syphilis or any other veneral disease? (h) Cancer or leprosy? () Any disease of the ear, nose or eyes, including defective sight or hearing? In the case of discharge from the ear, state when it was last noticed. @ Malaria, typhoid, influenza, kalaazar, filariasis or any other fever lasting for a week? (i) Any other illness within the last five years requiring treatment for more than a week?11. Have you ever passed blood, pus, albumen or sugar in the urine? 12: Have you ever had any operation accident or Injury? Iso, give details. 13, Were you medically advised to have a change of place for health reasons? If so, give reasons and state when and how long. 14. [a] Have you ever had any operation, accident or injury? (b] Have you ever had an electrocardiogram X-ray screening, blood, urine or stool examination? [c] Have you ever been in any hospital, asylum sanatorium for check-up, observation, treat- ment or any operation? 15. State the name and address of your usual medical attendant 16. Is any member of your family at present sulfering {rom insanity, tuberculosis, syphilis, cancer, epilepsy diabetes or any mental or nervous diseases? If so, give details: 17. For female candidates only (2) Have your menstrual periods always been regular and painless and are they so now? (b) How many conceptfons have taken place? (¢) Are you pregnant now? (@) Have you had any abortions or miscarriages? ~ DECLARATION , hereby declare that the information given by me in this Statement is true and correct and that if any untrue information is found to be contained therein, | shall be liable for such action ae the Company/Corporation may deem necessary Dated at ... this, saday of... Signed in my presence : (Signature of the Candidate) (Signature of the Medical. Examiner)UNITED INDIA INSURANCE CO. LTD. CONFIDENTIAL Regd & Head Office United India House 24, Whites Road, Chennai - 600 014. MEDICAL REPORT Ref. No .. Name of the Candidate 1, (a) Is the general appearance of the candidate healthy? (b) Are there any physical defects or deformities? (c) Describe personal marks or peculiari- ties by which he / she may be identi- fied. 2. Is there any evidence of skin disease, varicose veins, filariasis, enlarged lymphatic glands, swelling of the joints, marked anemia? 3. Following examination to be carried out : (a) Weight and Height (b) Condition of Eyes, Ears and Throat (Blindness, Deafness, Septic tonsils etc.) (c) Condition of Chest. Any tuberculosis of lungs, bronchitis or asthma. i, Chest (over nipples) stripped. ii, Abdomen (over naval) stripped (4) Condition of heart-Any valvular disease, enlargement, Any personal history of rheumatism, chest pain, hyper tension, coronary thrombosis. (e) Pulse () Blood pressure to be recorded in all cases (9) Condition of digestive tract-any history of ulcer in stomach or deodenum-any signs of its presence. Any enlargement of liver or spleen. Weight ..... _ Kgs. Height «...-.....Ems. (i) On complete expiratior Gi) On full inspiratio mm. Hg. Diastolic. mm. Hg (disappearance of sound) PTOSp. gravity Sugar Albumen Deposits (h) Urine - to be examined in all cases for albumen and sugar (i) Inall cases examine for inguinal hernia and if present whether a wallfitting truss Is regularly worn. (f) Inquire into personal history of accident, injury, operation, fainting fits, paralysis etc. 4, 1s he/she, in your opinion, mentally and physically fit for appointment in the General Insurance Industry. 5. To be filled in by female candidates ‘gnly in the prosence of the Medical Examiner : a) Are you married? b) If so, please state : Husband's name in full and occupation (ii) Are you pregnant? (iti) State the number of children, if any, and their present age ' hereby certify that | have this day examined the above candidate personally, in private and have recorded in my own hand the true and correct findings. | declare that | am not related to the candidate, In my opinion, he/she is mentally and physically fit for appointment in General Insurance Industry. Dated at . day of . 200 Signature of the Medical Examiner. Signature of the candidate PARTICULARS OF THE MEDICAL EXAMINER Signature . Medical Examiner's Code No. (Alloted by the LIC of India) Association's RMP No. Name in Full and address Medical Degree .. Year in which the degree was obtained