AIA lnsurance Lanka PLC rco. No.

po 1B)

Head Office
P O Box 2088
75, Kumaran Ratnam Road,
Colombo 2, Sri Lanka i
T: (+94 11) 231 0310
F : (+94 111 231 4179
E : lk.info@aia.com
AIALIFE.COM-LK

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PART TWO - MEDICAL STATEMENT
(To be completed by the Hospital/Medical Officer)

(1 ) ls the patient known to you personally or professionally?..

(2) Are you satisfied about his/her identity?....,

(3) Ward / Room No:.............. (4) RegistrationlAdmission/BHT No:

(5) Source of admission: OPD / Self Referral / Referred by another Medical Practitioner or Hospital
(6) Date of admission:.
(7) lf accident, date and nature of the accident:

(8)NatureofiIIness/injury&medicalcondition,"o,,"n.,",,,;,";,,";

(9) Please give the date of diagnosis:....

(10) Date of first consultation regarding this ailment and the doctor's name...,

(11) Pleasegivethedateonwhichthepatientfirstbecameawareofanysignsorsymptomsofthiscondition:..................

(12) ll surgery/ies was done, please give details of surgerylies:..... ".......,

(1 3) Was the onset of the illness acute, sub-acute or chronic?. "......

(14) ls the duration of illness stated by the patient compatible with your findings?......

(1 5) By whom the history of illness or disease was reported? .. .. . . . .

(17) l'f not discharged, probable period of treatment in Hospital/Nursing Home:..

(18) Was any period spent in an lntensive Care Unit:Yes / No

if yes, Date of admission to ICU ........ ......... Date of dischargefrom |CU......

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ipi"rr"gi;"iJttn"r"oi t'";;;i;;i;rri;;;j
being the Medicarofficer/surgeon/physician attached to """'
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"iHorpituir
do hereby declare that the foregoing statements are true and correct to the best of my knowledge and belief.

D;i; sig;"t;i"
"iM;i;,iorri;;;
Qualification & Designation

SLMC Registration No.

Name & Address of Hospital....

(Official Rubber Stamp providing above details to be placed)