GROWTH, CYSTS, LUMPS, AND TUMOURS QUESTIONNAIRE

SOALSELIDIK KETUMBUHAN, SISTA, GUMPALAN DAN TUMOR

Proposal Number/Nombor Cadangan : 200213314

Name/Nama : SALLIANA BINTI ABU SAMAH

New NRIC No/Nombor KP Baru : 850311125160

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1. When was the growth, cyst, lump or tumour first discovered? / Bilakah ketumbuhan, sista, gumpalan atau
tumor pertama kali diketahui?

2. Please provide the name of doctor or clinic and address. / Sila berikan nama doktor atau klinik dan alamat.

3. In which part of the body was it situated? / Bahagian badan manakah ia terletak?

4. Please state the precise diagnosis if known. / Sila nyatakan diagnosis dengan tepat jika ketahui.

5. How was growth described? / Bagaimanakah ketumbuhan digambarkan?

[ ] Benign / Benigna [ ] Malignant/ Malignan [ ] Adenoma / Adenoma

[ ] Cancer / Barah [ ] Fibroma / Fibroma [ ] Carcinoma / Karsinoma
[ ] Cyst / Sista [ ] Metastatic / Metastatik [ ] Papilloma / Papiloma
[ ] Invasive / Menyerang [ ] Haemangioma / Hemangioma [ ] Lipoma / Lipoma
[ ] Myoma / Mioma [ ] Neuroma / Neuroma [ ] Polyp / Polip
[ ] Others, please specify / Lain Lain, sila beri keterangan : _____________________

If the growth was described as malignant type, please attach histopathology ( HPE ) report / Sekiranya
ketumbuhan digolong ke dalam jenis malignan, sila berikan laporan histopatologi.

6. Has the growth been removed? / Sudahkah ketumbuhan disingkirkan?

If NO, please provide: / Jika tidak, sila berikan:

a. What the attending doctor recommended. / Keterangan tentang penyiasatan yang dijalankan, termasuk
tarikh dan keputusan ujian.

[ ] will continue to follow up? ada sebarang rawatan susulan sekarang?

next follow up date / tarikh rawatan susulan ____________
[ ] refer to specialist(s) / rujuk kepada pakar-pakar perubatan
please provide name and address / sila beri nama and alamat __________________
[ ] propose biopsy / further investigation (e.g. mammogram, CT scan, MRI, blood test, ultrasound,
etc ) / cadangan biopsi / penyiasatan selanjutnya ( mammogram, imbasan CT, MRI, ujian
darah, ultra bunyi, dsb )
[ ] propose surgery / mencadang pembedahan
please provide the date / sila berikan tarikh ___________________
[ ] propose chemotherapy or radiotherapy / mencadang kemoterapi atau radioterapi
[ ] propose treatment or medication / mencadang rawatan atau mengambil ubat
please provide details of treatment or medication / sila beri keterangan mengenai rawatan / ubatan
_________________________
If YES, please provide: / Jika YA, sila berikan:

a. Date of surgery. / Tarikh pembedahan. ______________________

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 b. Method of treatment. / Kaedah rawatan.
[ ] surgical removal / pembedahan untuk mengyingkirkan
[ ] radiation / radiasi
[ ] frozen / pembekuan
[ ] chemotherapy / kimoterapi
[ ] medication, drug therapy / ubatan, terapi ubat
[ ] others, please specify / Lain-lain, sila nyatakan: ______________________

c. When was the last treatment? / Bilakah rawatan terakhir diberi? _________________

d. Do you have histopathology report ( HPE ) on this condition ? If yes, please provide a copy. / Adakah
anda mempunyai laporan histopatologi untuk keadaan ini? Jika ya, sila sertakan satu salinan.

e. Are you still on treatment or follow up? If yes, what medications are you currently taking for this
condition? / Adakah anda sedang mendapatkan rawatan? Jika ya, apakah ubatan yang sedang anda
ambil untuk keadaan ini?

f. Do you have any recurrence? Please provide details. / Adakah sebarang ketumbuhan berlaku semula?
Sila berikan keterangan.
i) When the recurrence happens? / bilakah ketumbuhan berlaku semula?

ii) Where the growth was detected? / bilakah ketumbuhan diperhatikan?

iii) Any follow up? / Adakah sebarang rawatan susulan?

Please provide details / sila beri keterangan :
Name of doctor / Nama doctor _________________________
Address / Alamat ____________________________________
iv) Recommendation / Nasihat doktor

Please provide details, e.g, surgery, treatment / Sila beri keterangan cth pembedahan, rawatan

_________________________________________________________________________________________________

7. Has any future treatment been discussed or contemplated such as change in medications, surgery or other
therapy? If yes, please provide details. / Adakah rawatan yang akan datang dibincangkan/dipertimbangkan
seperti perubahan ubatan, pembedahan atau terapi lain? Jika Ya, sila berikan keterangan.

If NO, when were you discharged from follow-up? / Jika tidak, bilakah anda berhenti susulan?

8. Please provide any additional information on your condition which you feel will be helpful in processing your
application. / Sila berikan maklumat tambahan tentang keadaan anda yang anda rasa akan membantu dalam
pemprosesan permohonan anda.
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Declaration / Pengakuan:

I declare that the answers I have given are, to the best of my knowledge, true and that I have not withheld any material
information that may influence the assessment or acceptance of this proposal. I agree that this form will constitute part of my
proposal for Family Takaful and that failure to disclose any material facts known to me may invalidate the contract.

Saya mengaku bahawa jawapan yang telah saya berikan adalah, sepanjang pengetahuan saya, benar dan saya tidak
menyembunyikan sebarang maklumat penting yang mungkin akan mempengaruhi penilaian atau penerimaan cadangan takaful
ini. Saya bersetuju bahawa borang ini akan menjadi sebahagian dari borang cadangan untuk Takaful Keluarga dan
kegagalan untuk mendedahkan sebarang maklumat penting yang saya ketahui berkemungkinan membatalkan kontrak takaful
tersebut.

Signature of applicant / Tandatangan pemohon: Date/Tarikh:

_______________________________ __________

Statement of Witness / Kenyataan Saksi:

I hereby certify the above signature was made in my presence and that to my own personal knowledge it is the signature of the
applicant under the proposal mentioned as above.

Saya dengan ini mengesahkan bahawa tandatangan di atas dibuat di hadapan saya dan setakat yang saya ketahui tandatangan
tersebut adalah tandatanganOrang yang Dilindungi seperti yang disebut di atas.

Signature of Witness / Tandatangan Saksi Date/ Tarikh:

______________________________ ___________