Star Health and Allied Insurance Co. Ltd.

MEDICAL EXAMINATION REPORT

(To be filled in by the Medical Examiner)
Name of the person to be insured: ____________________________________________________________________
Date of birth: _________________

Age: _____________

Sex:

Marital Status: ________________ Occupation: _____________________________________

Identification Marks:(1) ________________________________________(2)_________________________________
1. Measurement & Vitals
Height(Cms)

BP *

Weight (Kgs)

Systolic

Diastolic

BMI

Waist Circumference (cms)

Pulse Rate
/Rhythm

Respiratory rate

I Reading:
II Reading:
III Reading:
*If the Systolic reading is 140 or more or Diastolic reading is 90 or more, second and third reading should be taken with 10
minutes interval of rest.
2. Personal Physician / Last Consultation:
Name and address of your personal physician (if none,
state the name of the doctor last consulted)

Date of last
consultation

Reason

3. Past History
Details of medical illness in the past

Period

Details of surgery/procedure undergone in the past

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Star Health and Allied Insurance Co. Ltd.

4.(a) If the person to be insured is presently suffering from any of the following diseases, please give details:
DISEASE

DURATION & DETAILS OF DRUGS TAKEN

DM/HTN
Orthopedics and related diseases

CVA/Neurological Diseases

Heart Disease/Respiratory Illness

Mental Illness

Renal Disease

Cancer

Other (specify)

(b) Within the past 4 years had he/she undergone any diagnostic test like blood test, ECG, CT Scan, MRI etc.,
If yes, please give details ________________________________________________________________________________

( c ) Details of illness for which OP treatment, IP treatment taken or any check up done during last one year.

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Star Health and Allied Insurance Co. Ltd.

(d) General Examination
Built
Nutrition
Anaemia
Cyanosis
Clubbing
Pedal edema
Lymphadenopathy
Others

5. Examination of systems
SYSTEMS
ENT & Opthalmology
Any evidence of cataract or surgery done for cataract (or)
Any other visible eye conditions.
Are there any missing teeth? If so, give details, Mouth Ulcers, Leucoplakia,
etc.,
Are there DNST/T & A/Ear Discharge & Hearing Loss

YES

NO

DETAILS

Respiratory System.
Are there any abnormality or diseases of the respiratory system like TB,
Asthma, COPD etc.?
Cardiovascular System
Is examination of CVS normal ?
Abdomen
Is there any organomegaly ?
Any Ascites
Surgical Scar if any
Is there any evidence of Hernia, hydrocele, undescended testis, chronic ulcer
etc.,
Nervous Systems
Is there any evidence of neurological disorder such as epilepsy, wasting,
involuntary movements, paralysis etc.,
Muscle Skeletal System
Examination of limbs, spine & joints

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Star Health and Allied Insurance Co. Ltd.

SYSTEMS
For female only
Is there any disease of the breasts? ( Lump )
Do you suspect any disease of ovaries uterus, cervix

YES

NO

DETAILS

6( a) Family History: Parents

If alive
Parent
Age

Present Health Status

Age at death

If NOT alive
Cause of Death

Father

Mother
(b) Family History: Diseases of parents
If any other family member is suffering from any of the following diseases, please give details
Relationship with the
person to be insured

DM

HTN

CVA

Heart
Disese

Renal
Cancer
diseases

Mental
Illness

Others
(Please
specify)

Medical Examiners Opinion :

Are there any Pre-Existing diseases?
If yes , give details

Any other remarks.

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Star Health and Allied Insurance Co. Ltd.

Is the person to be insured, related or known to Medical Examiner?

Signature of the person to be insured.

Yes/No

Name of the Medical Examiner.

Signature & seal.

Place:_________________

Date:____________

Address:____________________________

To be filled in by the Companys doctor/Panel doctor

Details of pre-existing diseases of the person to be insured to be incorporated in the policy:(1)
(2)
(3)

Name of doctor: __________________

Signature and Seal: _________________

Place: _______________

Address:____________________________

Date: ____________

________________________________________________________________________________________________

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