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Star Health an{ Allied lnsurance Co. Ltd.MEDICAL EXAMINATION REPORT

(To be filled tu by the Medical Exsminer)Nanc of thc Frson to be insured:

Mrit{l Slatus:Sexl

IdcnlificatnD Ma*s:(l) (2)

Weieht (Xqs)

*1fthe Systolic rcading is 140 ortnorc orDiastolic reading is 90 ormore, secondand third reading shorld bc t.tkcD $,iihminutes intenal ofresr2.( a) Famil) Histor]: Parenis

(b) Famil"v Histor]: Diseass ofp:rrntsWlether any one has suffered or is suffering liotn any ofthe followinr diseases, give delails

l- \'leasrremeni & Vit'ah

3. Personat Physician / Last Consultation:

l0

BP * Slstolic Diastolic PulseRateI Readjng:ITI Readin!:

U alive IfNOT alivePrcscnt Health Status Age at CauseofDath

Di$ase DetrilsRelationship ofthe person ( l.ho issufTring ) rvith the person to be

Stoke(ParahsislHearl Disease

Ofiers ( SDccif,, J

Name and address of the personat ph.l sicirn oftheperson to b insurcd (if non, stat th name ofthedoctor last consulted)Datc of last

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4. (a) Whethr the persor to be insured is sufiering fron any of th folloiring diseases, qive detailsDISEASE DETAILS

H}?etensionStrokc(paralysis)Heart DisascRenal Complications

often ( spcciS' )(b) In thc past 1 or 2 or 3 or 4 ycar(s), had he/she takcn X-ray. TMT,CT ScanlLing. MRI. Ulhasonosraphy, ECG, Blood

and Urine tests or ofter diagnostic tests such as ELISA, Australia antigen tesi etc ?Ifyes, sive detailsi

(c) Details ofillness for which OP treatment,IP treatment taken or any check up donc durjng last one yed.

E$minatior of systEmsSYSTEIITS \TS NO Df,TAILSf,YES & ENT

Is drcre my evidence ofpasr or prcsent disease of eyes. cinj. nose or throat?Has hdshe undergone tonsillitis opoation?Anv evidence olcatarict or cataractoLher eve oneEtion underqonelAre there any nnssing leeth? lf so, how n1!lry?RspiratorJ Systm.Are therc any slmproms or signs suggesting abnomrality or disease of rheresDiratoF svstem. evidence ofBronchial Asthfra or Trhtrdrlosi er.?Cardiovascular System(a) Does th hean sound nomal? Is anv munnurDresennO) Aie the pcripheral pulses nor,nal?(c) DctaiLs of sugery rmdergone, ifanyIs there any evidence ofenlargement of liver or sDleen?T\ there e! idenc olpllcsor fistulalAny abnomal mass palDable/tendemessSuEical Scar

HydroceleChronic LllceNEnlfgement ofPmstaleAny Mass lesionAny other opmtion undersone

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SYSTBNIS YtrS NO DETATI,SNervous Systemsh fiere any evidence ofnen or$ discasc, such as paralysis, epilepsy, wasiine.tremor. jnvoluntary movenents, etc?Genito - Urin!ry Systemls ilere any cvidence ofpast veneral disease?ls ieslis nomml in location, size and consistency? rany abnomalines presen!pleasc glvc delails?Dtails of accident.Is $ere evidcnce ofany operation or inju.ry due to accidenfifves. Dleasc indicate the extent ofdisahleme.rFor female onlyIs thdt ary disease ofihebrcasls? ( Lu p, any Mass lcsion )Is therc any evidence ofpresmrct ?Do you suspecl any dis.-ase ofuterus, cewix or ovadcs?Is there any surgical fealures related io childbirth or miscarriage?

Medical Eraminer's Opinion :

Are there any Pre'Existing diseases?lf yes , give details

' ls the per,on ro be ir,u cJ, -eldred or kno$ , ro Medical I \aminer. \ es \oSignature of the person to b insured. '

Date:

Nrme ofthe Medical Examiner.Signrtur & seal.

To befi edin by the CompanyJs doctor,lPanel doctorDetails ofpre-exjsting diseases ofthe person to be insured to be incorporated in the policy:-(1)(2\(3)

Nsrne of doctor:

Place:

Signsture and Seal:

Date:

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4\tedic!l Ir!min!iion in respect otHalrh Policics:

rorpcfons *nh advese lvledical Hislory and aged tr.Il.sals abole 50 yelrs. colense h subiect {o the lollosins erarnrnotionsIlowevcriorSenrorcrri,e. ed Supersqrlus policics this nrdical c{annral . n nor conpulsor,.

> \heE the trCC is abnomal Echo can be insiste{l at Insured\ cost to be doubLy clear atont tnc risk.> ln casc ofdonbl we can asl the Insurtd to himself/hesellfornedical eam.. loi d, l:. r, 'eq'eq o reJ.al ,.' i.,er.JooEsirhPHOlOor l' lre-Mdicnl Exnninrtion for Siar Critictrc Polis

I lor SunInsnEd upto Rs. I lacE Ceneral Medical ExomnradonE F,stinsBlood susaD Unne exmnradotr for Albumnr,' SusarE EcC & Cardiac Evalualion Repor. fron 0 qralifiedcardnlosist (h cose of nonllailabililof quali,ied Crrdrologi$. a Fa.licins Crdiolosist th MDquali licaiion nar be appDacbed)

0 ure. 'ar J',o". dc .-arJ,r.. oo.e,riGynac.ologisr (MD/DCo)2. lorSnn lrNucdabolc Rs. I LacQ Ceneral Mcdical ExarninarionO rdtins Blood SuraiD ru e +!n nB on 'or qlbrnn \' srE| lcc & cardiac lLairari.n Repod lon a qua|fiedCddiolosisl (ln cxse.l non avnihbilily .rqualited Cadioloeist.3 pra.licing Cardnnosisl rvrth MD qualitcalion nay beE ?eNic ljlra s.und scan

I For Sun lnsuGd uplo Rs. I lacE cd.nl Medioal lxahinatonO Fasliag Blood SugarE Unne exaniindton lDralbumi. / SusarO lCG & cardiac Eraluarion ReFn fti. ! quaMed2 lior Sum Insuied abovc Rs I la. lnd uDlo Rs.O F.$ing Bl.odSugarO UrnE cxxnimti.n br Albunlin / SugarQ LCC & cardiac E aLuarion Retorl liorn aE 'lEad l4il1 no lrcad nill rcsi ior !.*ons abole 60 ye{s ofr ,o \, r tr,i.Q C e!.ral M.d i.al rxaninx rio.Q Unne erddnalion for albnnin i SugarO ECG & Cediac Evatuation Rep.n non ! qualifiedQ Tread Mill Gnbjcd to thc opinion or the CBrdioloEisl l, nor c.'d ni rc. L'F ^ .,D, e,0)ear o arc.

I4prl!9!!-c!.s!.950-r93!! For persons upto 50 vears

(a) Forall sum insuedUsual Medical exminarion ap!1ica61e lin lvledicla$ic plusSerun Creatinine and Micro Albuminnre!.

G) for sur insuEd olRs.2la.s:NO medi.alcrsminrrl.n

( b ) Ior sun insucd ontions .l dbove Rs 2 lscsU al nedical exanrinalion applicable for abolc 50 yca^ tlusSdrun Cre,tirine rnd Micrn Alhnninnr.n