Attending Physician Statement

To enable us to assess your application, kindly get this form completed and duly signed by your
attending physician.

Name of Life Assured

Quote Number

(A)Condition History

1. Diagnosis made

2. Date symptoms first appeared or

accident occurred
3. Date of last visit for the condition
4. Has this patient ever had a similar
or related condition?

5. Or any other condition that you

are of.

(B) Treatment
Describe the patient’s treatment program.

1. Medications
(specify dose and frequency)

2. Surgery done

3. Specify whether any surgery is

advised or planned
4. Physiotherapy / Counseling

5. Is the patient still on treatment?

6. If No, specify test(s) done and the

results thereof, on the basis of which
the treatment was stopped.

7. Was there a recurrence post first

episode?
 Name of the Attending (C)
Physician

Address

Registration Number
&
Qualifications
Telephone Number
Prognosis
Recovered Improved
1. Patient’s condition has
Unchanged Deteriorated
2. Is the patient fit to resume work?

Please provide any additional details you may consider relevant;

__________________________________________________________________________________
__________________________________________________________________________________

Name and Address of attending physician

Signature of Attending Physician who has completed the report ___________________________

Date;