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  • X-Ray of Chest

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    Sanjay Bafna
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    The document is a report form for an x-ray of a life insurance applicant's chest. The form includes sections for the radiologist to provide details on the condition of the applicant's lungs, pleura, heart, aorta and any abnormalities. It also specifies requirements for the x-ray such as a focus distance of 72 inches and exposure time of no longer than 1/10th of a second. The radiologist must also declare that the applicant was present during the x-ray and sign and date the report.

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    X-RAY OF CHEST

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    The document is a report form for an x-ray of a life insurance applicant's chest. The form includes sections for the radiologist to provide details on the condition of the applicant's lungs, pleura, heart, aorta and any abnormalities. It also specifies requirements for the x-ray such as a focus distance of 72 inches and exposure time of no longer than 1/10th of a second. The radiologist must also declare that the applicant was present during the x-ray and sign and date the report.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    21 views1 page

    X-Ray of Chest

    Uploaded by

    Sanjay Bafna
    The document is a report form for an x-ray of a life insurance applicant's chest. The form includes sections for the radiologist to provide details on the condition of the applicant's lungs, pleura, heart, aorta and any abnormalities. It also specifies requirements for the x-ray such as a focus distance of 72 inches and exposure time of no longer than 1/10th of a second. The radiologist must also declare that the applicant was present during the x-ray and sign and date the report.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    ANNEXURE II - 9

    Life Insurance Corporation of India


    (Established by the Life Insurance Corporation Act 1956) _______________ DIVISION REPORT ON X-RAY OF CHEST (P.A. VIEW)
    Zone Proposal No. Agent / D. O. Code Full Name of Life to be assured : Age / Sex Division Introduced by : Branch (name & signature)
    Form No. LIC 03 010

    Instruments to Radiologist: a. b. c. d. Report : 1. Condition of Lungs and Pleura (Full details of abnormality if any, should be given) 2. Heart and Aorta a. b. c. d. Transverse diameter of heart Transverse diameter of Aortic Arch Cardio thoracic Ratio Any Changes, such as Arteriosclerotic changes and calcification of aorta etc. Film focus distance should be 72 inches Exposure time should not be longer than 1/10th second The x-ray plate should be taken in the vertical position of the patient in deep. The x-ray plate must bear name of the proposer, your initials and date.

    3.

    Conclusions

    I declare that the person (investigated) signed (affixed his/her thumb impression) in the space earmarked below, in my presence and I am not related to him/her or the agent or the Development Officer. Dated __________ on the ___________ day of 200 _________ at _______ am / pm ____________________ Signature of the L.A. ______________________ Signature of the Radiologist Name : Address : Qualification : LIC Code No.:

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