Attending Physician’s Statement

for Proposed Insured/Owner

Policy Number

Please fill in block letters & tick appropriate boxes and circles.
A. Personal Information of Proposed Insured / Owner
Last Name First Name Ext Name Middle Name

m m d d y y y y
Date of Birth: / /

B. Attending Physician's Statement

Date Attended Complaints and Duration of Illness Diagnosis Describe Treatment

m m d d y y y y Abnormal Physical i n da ys /weeks /yea rs
/ /
/ /
/ /
/ /
/ /

Laboratory Findings
Laboratory Tests Date of Test Test Result
m m d d y y y y
CXR / /
ECG / /
TMST / /
Biopsy Results / /
Others / /

Present Conditions (include sequel and complications of reported illness)

Have other physicians or surgeons been consulted? Yes No If yes, provide details below.
m m d d y y y y
Attending Physician : Date of Last Consultation/ Check Up: / /
Clinic Address : Nature of Disorder:
m m d d y y y y
Attending Physician : Date of Last Consultation/ Check Up: / /
Clinic Address : Nature of Disorder:
Do you smoke? Yes No If yes, provide details below.
Number of years : ____________________________
Number of sticks per day : ____________________________
Type of Cigars smoked : ____________________________
C. Affirmation Section

I certify that the above answers are based on medical examination record in my clinic for the above Proposed Insured/Owner that I have
attended to.
mm d d y y y y
Place Signed : Date: / /

Printed name of Medical Examiner : Signature of Medical Examiner :

PRC No. : FWD No. :

APSV206112014