Medical Examination form (for Distribution ... - Great Eastern Life

Great Eastern Holdings Limited (Reg. No. 1999 03008M)The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)The Overseas Assurance Corporation Limited (Reg. No. 1920 00003W)Medical Examination FormProposal No:Policy No:Life Planner / Rep. Name:Life Planner / Rep. No:Individual Life AssuranceGroup InsuranceAPERSONAL STATEMENT (Questions to be answered by the Examinee)*Mr / Mrs / Ms / Miss / Mdm / Dr1) Name of theLife to be Assured2a) Age: b) Sex Male Female * c) NRIC / Passport No / BC*:3a) Occupation:b) Name of Company:4) What is the name and address of your regular doctor or any doctor that you have attended in the last 3 years?Life to be AssuredName ofDoctorAddress ofDoctorDate and reasonfor last visitto your doctorPLEASE ANSWER THE FOLLOWING QUESTIONS5 Are you now receiving or considering to receive any form of medical treatmentor investigation from a doctor, or intending to consult any doctor for anyreason?Please TickYes NoIf answer is “Yes”, pleasesupply full details belowNature of treatment:Name and address of doctor:6 In the past five (5) years, have you ever had any tests done such as X-ray,ultrasound, CT scan, biopsy, electrocardiogram (ECG), blood or urine test?7aHave you ever smoked during the last twelve (12) or twenty four (24) months?Smoker in last twelve (12) monthsSmoker in last twenty four (24) monthsb Do you now smoke? No. of sticks per day:c How many years have you been smoking? No. of years:d8aHave you ever been advised to stop smoking by the doctor?Have you ever taken addictive drugs / narcotics or been treated for alcoholismor drug addiction?b Do you consume beer, wine or other alcoholic beverages? Type of alcoholic beverages:Average daily consumption:If any answer is “YES”, please give details, including dates, duration,diagnosis, name(s) and address(es) of all attending physician(s) and medicalinstitution(s)Have you ever had or been told to have or been treated for:9a Diabetes, thyroid disorders or any other endocrine disorders?b Asthma, bronchitis, persistent cough, coughing with blood, pneumonia,tuberculosis, chest or breathing complaints / discomfort, or any other lungdisease or disorder?c Raised cholesterol, high blood pressure, heart attack, heart murmur, mitral valveprolapse or other heart valve disease or disorder, breathlessness, irregular / fastheart rate, chest discomfort / pain, cardiomyopathy, disease of or any otherdisorders of the heart or blood vessels?deEpilepsy, fits, stroke, paralysis, weakness of limbs, prolonged headache,unconsciousness, nervous breakdown, depression, or any other nervous /mental disorders?Gastritis, stomach / duodenal ulcer, blood in the stools, fistula, piles, or anyother stomach / bowel disorders?fJaundice, hepatitis B carrier or any form of hepatitis, liver disorder or gallbladder disorder?1 Pickering Street #13-01 Great Eastern Centre Singapore 048659Email: nbu@lifeisgreat.com.sg Facsimile: 6536 1505 Website: www.lifeisgreat.com.sgNBMED112010

Proposal No:Policy No:Agent Name:Agent No:CMEDICAL EXAMINER’S CONFIDENTIAL REPORT*Mr / Mrs / Ms / Miss / Mdm / DrName of theLife to be AssuredNRIC / Passport No / BC*:It is presumed that when a Medical Examiner recommends a risk, he has determined to his entire satisfaction that the Life to be Assured is freefrom disease or from the effects of disease, and that he is likely to live as long as a normally healthy man of his age. The Medical Examiner isrequested to send this report in a sealed envelope as it is strictly confidential between the Company and the Medical Examiner. The MedicalExaminer is also requested not to give the Life to be Assured any information as to the result of the Examination. Please note that we may beobliged to disclose results of the medical examination to the examinee at his request.Has the weight increased, decreased or remained stationary during the past two years?Give an explanation for any marked change.Height:mCircumference of chest in full inspiration:cmWeight:kgCircumference of chest in full expiration:cmCircumference of abdomen at umbilicus:cmQUESTIONS1aAre you personally acquainted with the person under examination?If so how long, in what capacity and for what medical conditions?Please TickYesNoPlease give all detailsof any abnormalityHow many years?bcDoes appearance of the examinee correspond with the age stated?Does the examinee seem to be a person of sober habits?2 CNS, MUSCULO-SKELETAL SYSTEMa Are there any abnormalities in these two organ systems?b Are the tendon reflexes normal?c Are there any paralysis or tremors?d Are there any diseases of the spine or joints?3 CHESTa Is the chest symmetrically formed? Do both sides move equally?b Percussion - are there any areas of pathological dullness?c Auscultation - are the breath sounds normal?If not, please describe the abnormal sounds heard.4 HEARTa Is the apex beat normal?State where the apex beat is felt:b Is there any sign of hypertrophy or dilatation?c Are there any murmurs?d Is there any cyanosis or undue breathlessness on exertion?e Blood pressure - If it is found to be in excess of 140 Systolic or90 Diatolic (5th phase), please take two further readings with intervalsof 5 minutes. (By auscultatory method only)f Pulse Ratebeats / minutes (*Regular / Irregular)5 ABDOMENa Are the liver, spleen and kidneys palpable?b Are there any abnormal masses such as hernia, tumour etc?6 ENDOCRINEAre there any disease of the thyroid or other endocrine glands?7 ENTAre there any ear, nose or throat abnormalities?SystolicDiastolic1 2 3

QUESTIONSPlease TickYes NoPlease give all detailsof any abnormality8 Are there any disease of the eyes? Visual acuity *Aided / UnaidedRightDistantNearLeft9 URINARY AND REPRODUCTIVE ORGANS Urine Examinationa Are there any diseases of the urinary and genital organs eg varicocelecalculus?b Are there any scars or other signs of disease past or present?PH Albumin Sugar BloodPus cells / otherabnormalities10 FOR FEMALE APPLICANTS ONLY:a Is she now pregnant?How many months:b Are there any lumps or lesions in the breasts?c Are there any obstetrics or gynaecological abnormalities whether past /present eg: miscarriage, fibroid, ovarian cyst(s) etc?d Is she currently having her mensuration?11 a Does he / she have any visible growth, tumour or enlargement? If so, please state its location and nature:b Is there any significant change in his / her appetite, weight and bowel habitsrecently?If so, please elaborate:c Are there any special features in personal, family, recreational oroccupational history which you think are significant?12 Is there any further evidence, medical or otherwise, desirable to enable acorrect judgement of the risk?DDOCTOR’S REMARKSFrom the statements issued and from the medical examination, please state your opinion of the examinee with reference to the proposed assuranceas to the eligibility for assurance:*Assurable / UnassurableI certify that I have seen the Life to be Assured’s Identity Card No. / Passport No. / Birth Certificate No. ,the photograph of which bears resemblance to the person whom I have examined.Signature of Medical ExaminerDate :Name of Medical Examiner :Qualification :Clinic No. :Note: Please check your answers to ensure that nothing has been omitted.FOR OFFICE USE ONLY:*Please delete accordingly.