AIAPUBLIC TAKAFUL ATTENDING PHYSICIAN'S STATEMENT c [AIA PUBLIC Takaful Bhd, (95955) al lliness - Coronary Artery Disease Requiring Surgery/Other Serious Coronary Artery Disease/ Angioplasty/Heart Attack To bo completed by Registered Medical Practitioner at Person Covered's / Claimant's own Create No 1c We ao Name of Person Covered 0 Gondor: [J Male Female Note Please ck) the LL] coronary Artery Disease Requiring Surgery Tear attack Jovan singnosis | other Serious Coronary Artery Disease TF Anaioptasty and Other Invasive Trestments for Coronary Artery Disease Part |- General Information 1 (Ayes e Pen Corece mines scr? |1, «Clos CI ne (1 eo wat rd ou cr » 2 a)inenwue outed othe ees? | 2. moon 0 Recor oe patan? 0 omis___ te Montis_____Yoats i inyurmedea phon? o_o aye vies Mons 2. (0) Hasna Prsn Cavers prov utr am (011 Yee" ploase give datos of consutatons and ‘he reciting sagrost (c) Waste patent referee you? One 3) Les © Live Ono (18%, when? 0 (moore (0) Reasone tor ctor? w. (i) Name and acres of he referral doctors ) 4. (2) Onwhat date was the diagnos made? 4) aware () Qn date wash Pron Covered at made w worry) fay history which woul have created a sk nos 5, Which of he olbning actors represen? ‘ate of Onset (MRIDDPYY) Freussant9 v2.0)Part!!- Details of the Person Covered's lines. 1. Please provide fall ant exact dla of he agnosis, | 1 (a) Viten stres ae inales and wha he “ ‘Sopree of narrowing (i) reapoe oF 2208 fetes ate? {b) Was coronary ateriography performed? ©) C1) ves date Performed orvyyy — L] No 3. Walia the nature of tetent? a (a) Ws open hea surgery poformed? C1 vee vateratormeg ory) Co (0) Yee tate te number and ss of grate ® (6) Was batbon angloplesry, hereon o ser ce O Yes Date Pecormed moore — 1 no treatment was done, (Wits tactrsinannee tens — | ove oor we (one aan « supa avanrusaycargentccrsmeds | Cle Che {6} Troponin T> 1.0 gin or equivalent threshold with wo Dves Ono 5. Was the Porson Goverod treated ty ay oor doctors or |s: L]ves LJ) no 6. Has the Parson Covered sufered rom /bsen vested or |6. — Lves LJ no. 1. thers any futher formation which inyour opinion |7. Ll yes no Note: Pass enclose copies o post bypass report, angagrama, Post PerostaneousTranaluminal Coronary Angapaty (PTCA, ECGs, Caria Enzymes assay Troponin Tes Eshociogran an apts igre, CI scan, yar Magog sues, Kowa eee, and ay rbrnt henprepas hat we ‘hereby catty that nave personally oxarned and treated he Person Covered for his neni / esses deserbed above an that the acs as sated above repre ‘sent my medal opinion s/s ner conden ‘Signa of Atnding PRyosian usifeaton Name & Adress (tical Stamp) bate amon Frome 20 Paap Bot?