GENERAL PRACTITIONER’S MEDICAL REPORT

1a. FULL NAME 2a. DATE OF BIRTH 3. MARITAL STATUS

2b. AGE NEXT BIRTHDAY 4. How long have you been

1b. PHONE NUMBER: married?

5. Have you ever had or been told you had…… YES / NO

a. Fits, Nervous Breakdown, Overwork or any nervous or mental disorder, Anemia?

b. Blood-spitting, Pleurisy, Tuberculosis or any Lung Disorder?
c. Ulcer, intestinal or biliary disease, or any other abdominal Disorder?

d. Kidney stone, colic, bladder trouble or any other Genito-urinary disorder?

e. Rheumatism, heart disease, goiter, apoplexy or high Blood pressure, Sickly Cell disease?
f. albumen, blood or sugar in the urine?
g. Varicose veins, hernia, deformity, injury or any other ailment?
h. Yaws, leprosy, syphilis or malaria?

5i. Have you ever had an X-ray or other special investigation? YES / NO

IF ANY QUESTIONS IS ANSWERED “YES” ABOVE, GIVE FULL DETAILS BELOW

Question Date Ailment & Duration Last occurrence of Name of Doctor / Hospital
No. symptoms

7. FAMILY RECORD IF LIVING IF DEAD

Count Ages State of their Health Age at death Cause of Death
Father

Mother

Brothers
How Many?

Sisters

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 How Many?
8. Has any member of your family ever had YES / NO
a) Any heart Ailment
b) Nervous or mental disease
c) Tuberculosis?
d) Diabetes?

9. In the case of a female 10. Have you ever resided in any mining area in
a. Are you pregnant? ………………………………………….……………..………. West Africa? If so, where, and for how long?
b. Have you any children? ………………………………………………………….
c. How many children? …………………………Age of last child….………..
d. Have you had any female disease? ………………………………………...
If yes, state the ailment …………………………………………………………..

11. Have you ever …… YES / NO

a. had unexplained, recurrent or persistent fever or skin disorder?

b. had unexplained, persistent night sweats?
c. had unexplained weight loss?
d. had unexplained infections or swollen glands
e. had chronic or recurrent diarrhoea?
f. had persistent cough?
g. had hepatitis B or any sexually transmitted disease including genital sores or discharges?
h. had or been advised to have a blood test for AIDS or an AIDS related condition?
i. been refused as a blood donor?

IF ANY QUESTIONS IS ANSWERED, “YES” GIVE FULL DETAILS

Qus. Sate Disease or Injury or Date Duration Last occurrence Name of Doctor / Hospital
No. operation of symptoms

11g. Have you ever received any blood transfusions within the last five years? YES / No

If yes, when was that and the reason for the transfusion? ……………….………………………………………………………......................................................

……………………………………………………………………………………………………………………………………………......................................................................

11h. Have you ever been refused life or medical insurance, or has an insurance company offered you cover subject to a higher premium or
on special terms? YES / No

If "Yes" please give details…………………………………………………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………………………………………………………………………………..

11i. Does your occupation, hobbies or pastimes involve you in any activity which may expose you to a higher than average chance of
premature death or of becoming disabled. YES / No

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If "Yes" please give details…………………………………………………………………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………………………………………………………………………………..

11j. Do you Smoke? YES / Stopped smoking / Never smoked

If YES, state what and how much you smoke per day ………………………………………………………………………………………………………………………………

If Stopped smoking, when did you stopped smoking? ......................................, what did you smoked and how much were you smoking

per day?.........................................................................................................................................................................................................

11k. Do you take alcohol? YES / Stopped / Never

- If yes, state the type you often take and how much you consume per week. ……………………………………………………………………………….……….

Have you ever received medical advice to reduce / discontinue alcohol consumption? YES / NO

If yes, give details …………………………………………………………………………………………………………………………………………………………….……………………

- If stopped, when did you stop? …………………………………………, what type were you drinking and how much per week …………………………….

………………………………………………………………………………………………………………………………………………………………………………………………………………..

12. Have you been taking any regular medication in the past two years? .........................................................................................................

If yes, indicate the name of the medication, when you started taking it and what is being treated……………………………………………………………..

……………………………………………………………………………………………………………………………………………………………………………………………………………………..

I declare that the foregoing answers are true, that I have not withheld any important circumstance, and I agree that this declaration shall be
held to form part of the proposal for life insurance now made to the Company.

Date …………………………………………… Signature ………………………………………………….

*THE MEDICAL EXAMINER SHOULD SEE THE LIFE PROPOSED SIGN THIS FORM BEFORE PROCEEDING WITH THE EXAMINATION AND
MAKING HIS REPORT OVERLEAF.

To be completed by the Medical Examiner

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 2. Chest at nipple line
1.Height (exact)? m………….. cm……………….. Full inspiration
Complete expiration
Weight (exact)? kg………………………… Abdominal girth cm
(at umbilicus
3. State of Heart?
a. Rate and State of Pulse (a)

b. Blood Pressure (b)Systolic ……………………………. Diastolic…………………………….

(When the Systolic Blood Pressure exceeds 144mm, or the
Diastolic exceeds 90mm, fresh reading should be taken in the Systolic ……………………………. Diastolic……………………………
reclining position after resting for 5 minutes in this position) (2nd reading if required)

4. State of Lung?

5. Nervous System.
a. Are the pupils equal?
(a)
b. Do they react both to light and accommodation?
(b)
c. Are the knee jerks normal, absent, or exaggerated?
(c)

(a)
6. State of (a) teeth, (b) digestive organs
(b)

7. Where there is or has been infection of the ears,

(a) What is the condition of the drum? (a)

(b) Is there any discharge? (b)

8. Genito-Urinary System: - (a)

(a) Specific gravity of Urine? (b)

(b) State any abnormality findings

9a. What is the build and general appearance? (a)

b. Are there any signs of past or present intemance? (b)

c. Is there any evidence or suspicion of venereal disease? (c)

(Past or present)

10. Apart from the foregoing is there any other condition or

circumstance calling for remark?

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12. Additional Remarks:

13. Medical Summary:

Please give a summary and analysis of each test done.

________________________________________ _________________________________________________________________
Name of Physician Contact number & Address

________________________________________ _________________________________________ ______________________

Signature Medical qualification Date

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